name and last name         

company name                   

contact address                   


Telephone - Mobile phone

E-mail address                     

I want  to  advertse in your website dentist name 1 webpage no picture dentist name 1 webpage with 1 picture dental clinic 1 webpage no picture dental clinic 1 webpage with 3 pictures add new dental clinic add new dental clinic 1 webpage make link to your website add new dental laboratory add new company company 1 webpage no picture company 1 webpage with 3 pictures make your homepage

starting from                           January February March April May June July August September October November December 2006 2007 2008 2009 2010 1 month 3 months 6 months 1 year 2 years 3 years 4 years 5 years Continuously

I agree to pay                         200 Baht 300 Baht 400 Baht 500 Baht 600 Baht 800 Baht 900 Baht 1,000 Baht 1,200 Baht 1,400 Baht 1,500 Baht 1,600 Baht 1,800 Baht 2,000 Baht 2,100 Baht 2,400 Baht 2,500 Baht 3,000 Baht 5,000 Baht 10,000 Baht 15,000 Baht 20,000 Baht  

By transferring this amount of money to  Mr. Natthapol Yospaiboon ,

Siam Commercial Bank  , Sukhumvit 71 Branch

Saving account  Number  071-2-59956-5

Date of Transfer