Display ad insertion order form

WRITERS’ Journal
Display Advertising Insertion Order

If you require assistance in completing this order form, please call: 218-346-7921.

Please FAX this form to: 218-346-7924 or mail it to: Val-Tech Media, P.O. Box 394, Perham, MN 56573

Date: ____________________

Space in WRITERS’ Journal is hereby ordered subject to conditions stated below.

Advertiser

Name: _________________________________________________________________

Address:________________________________________________________________

City: __________________________________ State: _________ Zip: _____________

Contact: _______________________________ Phone: __________________________

Fax: ___________________________

Web site:_______________________________E-mail:___________________________

Agency/Accounting (If applicable)

Name: _________________________________________________________________

Address:________________________________________________________________

City: __________________________________ State: _________ Zip: _____________

Contact: _______________________________ Phone: __________________________

Fax: ___________________________

Web site: ______________________________ E-mail: ___________________________

For advertising guidelines, ad requirements, closing dates, and terms and conditions please see our online media kit at: http://www.writersjournal.com/newonlinemediakit.htm.

Issues (Circle): J/F M/A M/J J/A S/O N/D

Rate Frequency (Circle): 1 Time 3 Times 6 Times

Ad Size (Circle): Full Page Half Page (horizontal) Half Page (vertical)

Quarter Page Eighth Page Specialty Advertising/Insert

Position (Circle if applicable):

Cover 2 (inside front) Cover 3 (inside back) Cover 4 (back)

(Circle one):

Black & White Color

Rate: Please see our rate card, or visit: WRITERS' Journal Online Media Kit for our detailed ad rates. If you have been quoted an ad rate, please state the name of the ad representative. We allow the standard 15% commission to recognized ad agencies.

Rate: ________________________________________________________________________

Name of authorized WRITERS’ Journal ad representative:

________________________________________________________________

***FIRST-TIME CUSTOMERS: YOUR FIRST INSERTION MUST BE PAID IN ADVANCE***

To pay by check, print out this form and mail it with your check, payable to:

Val-Tech Media
PO Box 394
Perham, MN 56573

To pay by credit card (Visa or MasterCard):

Card Number______________________________________ Expiration Date:___________

Name: ___________________________________________________________________

Address:__________________________________________________________________

City: __________________________________ State: _________ Zip: _______________

Fax to: 218-346-7924 Or mail to: Val-Tech Media, PO Box 394, Perham, MN 56573

Thank you! A WRITERS’ Journal representative will contact you to confirm your order.