Company:			Date:
Contact:			Account Exec:
Contact Email:			Bill To:
Company Website:			Billing Contact:
Mailing Address:			Billing Address:
Mailing City:			Billing City:
Mailing State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming		Billing State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Mailing Zip:			Billing Zip:
Phone:			Phone:
Fax:			Fax:

Wyoming	Wyoming	Wyoming
PREMIUM PLACEMENT	CATEGORY	AD SIZE	UNIVERSITIES

Ad Rate Per Market:
Placement Charge:			Check #	9 Digit Routing Number
Other:
TOTAL DUE:			Checking Account or Credit Card Number	Exp. Date
DEPOSIT: (Min 50% Required)
TERMS:
BALANCE DUE:			Credit Card Holder's Name or Bank Name
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