Insertion Order Form

Contact Information
(to be published with product or service description)
Company Name
Contact Name
Contact Title
Street Address
City, State
Zip Code
Telephone
Fax
Email
Web Site Address

Issue Year English Spanish
January/February
March/April
May/June
July/August
September/October
November/December
Industry Code

Ad Size
Display: Full Page    
  2/3 1/2 4/9
1/3 2/9 1/9
Listings: 1/9 2/9
Format: Vertical Horizontal
Color: 4-Color B&W
New Material Pick up from issue
Premium Position Request (Additional 10%)
Web Site Listing
Web Site Translation (Translation Order Form Required)
# of insertions Amount (per insertion)
Special instructions/positions request:
I agree to the terms and conditions of this Insertion Order.
SIGNATURE
PRINT NAME

Certification as a U.S. Exporter (Please select one of the following)
The entity seeking to advertise is a U.S. citizen or a commercial entity organized under the laws of the United States or of any State/Territory.
The entity seeking to advertise is a foreign-organized business that is 95 percent owned by a U.S. citizen.
The entity seeking to advertise is a foreign-organized business that is 95 percent owned by a commericial entity organized under the laws of the United States.

Billing :
Invoice Advertiser Agency
Agency Name
Street Address
City, State
ZIP Code
Telephone
Fax
Email
Contact Name
Contact Title

Payment (pick one): Check*
Visa Mastercard American Express
Credit card use authorized to secure Net 30 terms.
Amount to be Charged
Card Number
Security Code
Expiration Date
Cardholder Name (print)
Cardholder Signature
* Make Checks Payable to ThinkGlobal Incorporated
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