Commercial Purchase Order Form ( Writers ).

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: ________________________

________________________________________________________________________________

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: ________________________________________________________________________

Number of article / column:_____________________________________________________________

___________________________________________________________________________________

Total Number of articles / columns:______________ Total Amount: $_________ Prepaid shipment: $_______

Signature:______________________________________ Date:_________ In: ______________________

Fill out the order form with all details, signed and e-mail to: FPINS - Operations

To confirm your shipment or order call: (705) 745-5770