Advertiser:
Owner Name:
 
Contact Name:
Position:
 
Work Phone:       Alternate Phone: 
E-Mail:      Web Site: 
Best time to be reached:   Time   Days 
 
Address:
City:       State:       Zip: 
 
Newsletter:           Ad Format:  
 
Ad Size:         Pricing:       Term: 
Six consecutive issue 15-20% off ads (depending on newsletter)
Ad Layout Needed:      
Set Up Fees (if needed):   BC - $20,      ¼ page $30,      ½ page $40,      Full page $50
(Includes 2 revisions – Additional revisions $15 each)
 
Special Instructions:   
Payment: Check # 
Credit Card: Expires:   / CVCC: 
Limited Liability:  Advertisers are required to carefully review their ad copy and approve the final form. They are equally responsible for ad “correctness”.
Payments are to be paid in full before the deadline

By checking this box I understand and agree to the above statement of limited liability.