Please print this form and complete the information requested prior to faxing it to our attention:agreement for a link exchange with LASCMA.
NAME OF PERSON COMPLETING THIS FORM (LAST NAME, FIRST NAME):
OFFICIAL NAME OF ORGANIZATION SPOSORING THE SITE INVOLVED FOR A LINK EXCHANGE:
TITLE OF INDIVIDUAL COMPLETING THIS FORM ON BEHALF OF THE REPRESENTED ORGANIZATION:
ORGANIZATION'S URL ON WHICH OUR LINK MAY BE DISPLAYED:
ORGANIZATION'S OR REPRESENTATIVE'S OFFICE PHONE NUMBER:
ORGANIZATION'S OR REPRESENTATIIVE'S OFFICE FAX NUMBER:
ORGANIZATION'S OR REPRESENTATIIVE'S E-MAIL ADDRESS:
ORGANIZATION'S MAILING ADDRESS:
ADDITIONAL INFORMATION INCLUDING TITLE, DESCRIPTION ETC. MAY BE ADDED HERE.
(DO NOT ATTACH GRAPHICS OR HTML CONTENT HERE):
as outlined in Section 1 of the contents published at the url www.lascma.com/linkexchange.html.  I also understand this is only a request for an exchange of links to be published on either party's specified web-page. Until reviewed and a responce is received, LASCMA and corporate subsidiares are in no way obligated or bound to the request being made. Logos and graphical content may be bound under legal patent rights and must not be utilized or published on any site without prior agreement from LASCMA.
THANK YOU.
YOU CAN EXPECT TO RECEIVE A RESPONCE IN 7 TO 14 DAYS.
WE LOOK FORWARD TO WORKING WITH YOU!
http://
YOU MAY PRINT AND SUBSEQUENTLY FAX THIS PAGE TO
Attn: Emilie Jacobs
                                                                           LASCMA Administrative & Clinical Research Coordinator
                                                                  Fax:  323-913-2588
Request for a link exchange with LASCMA.COM.
LOS ANGELES SPECIAL CARE MEDICAL ASSOCIATES
Hollywood medical care
A DIVISION OF SAMPSON HEALTHCARE, INC.
By checking this box, I am indicating that I understand and agree to abide by the terms of agreement