| First Name: |
|
| Last Name: |
|
| Title: |
|
| Company: |
|
| Company Type: |
|
| Address: |
|
| Address: |
|
| City: |
|
| State (Province): |
|
| Postal Code: |
|
| Country: |
|
| Main Phone: |
|
| Fax: |
|
| Email: |
|
|
Image Number:
|
|
|
Intended Use:
|
(brochure, print ad, billboard, etc.)
|
|
Use Size:
|
(1/4 page, full page, double page, etc.)
|
|
Placement:
|
(inside, cover, etc.)
|
|
Press Run or Circulation:
|
(5,000 brochures or an ad in a 250,000 press run magazine)
|
|
Duration of Use:
|
(one-time, use for a year, etc.)
|
|
End Client Name:
|
|
|
I prefer to be contacted by:
|
|
|
Other Information: (ex: distribution location)
|
|
 |
|
|
