[Secure] Rockland News Ads Payment Form

Thank you for choosing Rockland News to advertise your business, organization or cause.

Please fill out the credit card authorization form below to process your payment for your sponsorship of this year’s Rockland Candidates page.

The cost for your placement is $49.95, paid one time to Rockland Web Design Inc.

If you have any questions, please contact us at (845) 877-7333, ext. 2.

We appreciate your business, and your help in supporting our free and local press.

4. Secure Credit Card Authorization Form

Your Name(Required)

First Last

Name on Card(Required)

First Last

Email(Required)

Phone(Required)

Company Name

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Street Address Address Line 2 City State ZIP Code

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CVV

(Three digit security code on the back of VISA/Mastercard, or four digit code on the front of AMEX)

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