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Advertising Insertion Order Form

Organization:(required)
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Contact name:(required)
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Email:(required)
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Telephone:(required)
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Fax:
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Address:(required)
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Address 2:
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City:(required)
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State / Province:(required)
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Zip / Postal code:(required)
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Country:(required)
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Ad Size:(required)

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Loose insertion:(required)
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Color:(required)
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Ad position:(required)

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Subject to availability.

Number of Insertions:(required)
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Price per insertion:(required)
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Insertion Date / Issue:(required)
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Copy / Headline:
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Digital file will follow by:

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Loose insertions will follow by:

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If applicable.

Authorized by:(required)
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Special Instructions, Other Information
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