Date Order Placed_________________________________When Needed____________________
Name of Person Placed Order_______________________________________________________
Name of Dealer___________________________________________________________________
Address Dealer___________________________________________________________________
City_____________________State_______Zip_____________
Tel#_____-_____-______ Fax#_____-______-_______E-Mail Address______________________
Website Address________________________________Contact Name_______________________
Credit Card: []Amex []Visa []Master Card []Direct Debit acct#_______________________________
Card#___________________________________________Exp. Date________________________
Name on Card___________________________Zip on card___________________________
Logo e-mail to: hlhirsch@earthlink.net [ ]E-mail silhouetted logo
as 150 dpi Tiff, BMP or JPEG formats.
Dealers shipping Preference: [] Fed Ex [] Airborne [] U.P.S.
Dealers Acct.#___________________________________
Shipping Preference: [] Overnite [] 2 Day [] 5 Day ground
If you need to update or add qualified prospect's to your
mailing, we can help. There are 4 ways you can order names.