WRITERS' Journal 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.