PO #
*
If you do not have a PO#, put "N/A"
Insertion Date
*
Please put the date you would like this insertion to start.
Client
*
Contact
*
Phone
*
E-mail
*
Please select one of the following rates*
*
One insertion - Hospital Corporate Supporter** - $1,200
One insertion - Regular - $1,500
Two insertions - Hospital Corporate Supporter** - $1,800
Two insertions - Regular - $2,250
Payment method for this purchase
*
Payment via Cheque
Payment via Wire Transfer
Payment via Credit Card (PLEASE NOTE THIS METHOD WILL INCLUDE AN ADDITIONAL 2.5% PROCESSING FEE)
Please make the invoice out to:
Skip this section if you are a returning advertiser with no changes to your invoice information.
Name
Organization
Address
City
Phone
Prov/State
Postal Code
Any special Instructions?
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Rates are subject to change at any time.
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