| Advertiser Name | |
|---|---|
| Company Name | |
| Contact Information | |
| Publisher Name | |
| Contact Information |
| Newsletter Name | |
|---|---|
| Banner Size/Specification | |
| Placement (e.g., Top, Middle, Footer) | |
| Issue Dates | |
| Number of Issues | |
| Ad Creative Due Date |
| Total Fee | |
|---|---|
| Payment Terms |
| Advertiser Signature | |
|---|---|
| Date | |
| Publisher Signature | |
| Date |