______________________________________________________________________________
Company Name
______________________________________________________________________________
Address
______________________________________________________________________________
City State Zip
______________________________________________________________________________
Phone Number Fax Number
If we have any questions concerning your advertisement, NITL staff should contact:
______________________________________________________________________________
Indicate the week(s) you would like your advertisement to run ___________________________
Select from the options below:
____ Lead Advertisement ____ Other Placement
$________ Total
Payment: ____ AmEx ____MC ____Visa ____Check (enclosed)
Name on Credit Card____________________________________________________________
Credit Card Number__________________________________Expiration Date________________
Credit Card Holder's Signature_______________________________________________________
Please call: (703) 524-5011 for assistance; fax: (703) 524-5017; e-mail: gilanshah@nitl.org
This form with payment must be received prior to the launch of any advertisement.