FPINS International - Writers
266 Charlotte Str. Suite 297
Peterborough. ON.
K9J 2V4 Canada             Writers Order Form No. 1.

Print out the form, and fax it to: (705) 745-9459. (This form must be signed.)

Date:_______________  Client or Subscriber Number: ______________________

New request:_______________ Deadline date/________time/__________

First Name:______________ Last Name:___________________________

Company Name:______________________________________________

Address:_______________________________ City:__________________

State / Province:__________ Zip / Post Code:_________ Country:_________

Phone No:( ____ )_______________ Fax No: (_____)_________________

E-mail:___________________________ Other:______________________

Article:  ____________________________________________________

Column: ____________________________________________________

Book: ______________________________________________________

Usage Type:

Advertising:______ Textbook:_________ Brochure:_______ Editorial:______

A/V:__________ Electronic:___________ Corporate/Industrial:____________

Other specify:__________________________________________________

Size:1/4 Page:______ 1/2 Page:_______ Full Page:_______ Cover: ________

Other:________________________________________________________

Distribution:

Local:________ Regional: _______ National: ______ International:_________

Specify Area: __________________________________________________

Rights:  One-Time Use:_____________ Other: _________________________

Print Run:__________________ Length of Time: _______________________

Is a Fax of Layout Herewith? Yes:____ No:___

Will a Credit Line be Used? Yes:____ No:____

Method of Payment:

Type of Credit Card : _______ Holder's full name : __________________________

Card number : ________________________  Exp. date : ________________

Western Union - Money transfer control number : ________________________ 

Money Order by :_______________________________________________ 

Entry details: __________________________________________________

Articles :________________________________________________________
______________________________________________________________

Total Number :______ Total Amount: $______ Prepaid shipment: $_____

Signature:__________________________ Date:_________ In: _____________

 

Fill out the order form with all details, signed and Fax the copy to:  (705) 745-9459
To confirm your shipment or order call: (705) 745-5770
or by e-mail to: FPINS - Writers

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