Secure Online Order Form

Contact Name (First & Last)
Real Email Address (For Contact Purposes)
Additional Email Address (That you want Promotional emails to go to)
Check here if you do not want Promotional emails (Submission will generate several hundred)
Site Title
URL/Web Address
Photo/Graphic URL (For Classifieds only)
Item (For Classifieds only - What you are selling/looking for)
Price (For Classifieds only - What you are charging)
Type of Site (What kind of site do you have?)
Headline (Classifieds only)
Site Description (Search Engine) or Ad Text (Classifieds) 25 Words or 255 Characters
Company Name
Street or PO Box Address
Zip/Postal Code
Area Code & Phone #
Fax #
Keywords (Choose up to 15 for Search Engines or Classifieds)
Banner Location:
Banner Ad Category
Services (Use CTRL to select more than one. All services are in US $.
How did you hear of us?

If you want to pay with PayPal, please go to PayPal and click on Send Money and send to, or ask us to send you a PayPal invoice.


Note: This is a secured site. Your personal information will remain confidential. We will contact you by phone for payment information, or you may fax to: 253-322-5778.

Check here if you would like a submission report
Check here if you have read the FAQ (Frequently Asked Questions)
Do you need a Webmaster?


Please click submit only once. Thank you for your order!

We accept Checks, Bank Wire, PayPal, Visa, Mastercard, Discover/Novus, & American Express.

Please contact us for Bank Wire info.
We Accept Major Credit Cards
All orders need to be paid in advance or at time of order.
International Orders take 2-7 days to complete.
Checks will be held until they clear, or funds will be verified before your order is processed.
For protection - Your IP address is being logged.

Ackley's Custom Site Submission (ACSS)

23161 N 89th Ave
Peoria, AZ 85383
(800) 969-9598 (Toll Free)
(623) 587-9499
Payment Processing by ICVerify  VeriSign Security  Privacy Guaranteed PayPal - Click to Verify Account Standing

All Rights Reserved  -   Ackley's Custom Site Submission
Web Site Designed by: Carla Ackley