Area Medical Clinic Brochure Ad Order Form
Contact Information
Business/Organization Name
Contact Person
Email
Phone
Address
Ad Selection
Select Ad Size:
Full Page
Half Page
Quarter Page
Eighth Page
Special Instructions / Placement Requests
Ad Materials
Artwork Provided
Camera Ready
Need Ad Designed
Payment Information
Payment Method
Check
Credit Card
Other
Authorization
I authorize the publication of our advertisement in the Area Medical Clinic Brochure. I understand payment is due upon order and all ad materials must be submitted by the deadline.
Authorized Signature
Date