Adampler Agent Information Sheet
Agent Name:

Customer Info:

Company Name:
Contact: Phone:
Address: Fax: Customer Email:
City, State, Zip:
Website: Accepts email proofs

Yes No Undecided

Payment Info:

Contract Signed: Yes No

Deposit Recieved (50%): Yes $

Payment Type:

Credit Cards Info (add 5% processing charge of total price)

MasterCard Visa American Express

Card Number:

Expiration Date: Payment Amount: $

Issue Info:

Williamsburg Adsampler

Issue:

Winter Early Spring Spring
Summer Fall Xmas

Size:

If different sizes per issue list below:

Yorktown Adsampler

Issue:

Winter Early Spring Spring
Summer Fall Xmas

Size:

If different sizes per issue list below:

Premium Placement Request: Promised Paid

Design Info:

Camera Ready Art Supplied: Yes No

Design Required: Yes No

Info to include in ad (check all that apply:)

Company Name Phone Number Website
Address Fax Number Email
Cell Number

Coupons: Yes No

Number of coupons:

Coupon Information:

Display Ad Information:

Photo Shoot Required: Yes No

Supplied images, logos, etc. saved in local folder Yes

File names:

No - Date to be recieved:

Supplied images, logos, etc. sent to FTP location Yes

File names:

No - Date to be recieved: