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FPINS
International - Writers |
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