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This page may be printed for your records.
Billing Information
| Advertiser Name: |
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| Billing Address 1: |
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| Address 2: |
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| City: |
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| State/Province: |
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| ZIP/Postal Code: |
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| Country: |
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| Phone: |
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| Fax: |
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| Website URL: |
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| Contact Full Name: |
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| Contact E-Mail: |
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| Contact Phone: |
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| Contact Fax: |
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Channel Advertising Options
| Channel |
Outreach Sectors |
Additional Resource Channels |
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Ad start date: //
| Ad Duration and Costs — |
| Duration and cost per channel: | $ |
| Number of channels checked: | |
| Total Cost of Ad Campaign: | $ |
| Click-thru-URL: | |
| Alternate Text: | |
| Banner file name: | |
| Uploaded Image file name: | |
Special Instructions:
Diversity Recruitment Advertising
Ad start date: //
| Ad Duration and Costs — |
| Duration and cost per channel: | $ |
| Number of channels checked: | |
| Total Cost of Ad Campaign: | $ |
| Click-thru-URL: | |
| Alternate Text: | |
| Banner file name: | |
| Uploaded Image file name: | |
Special Instructions:
| Campaign Cost — |
| Channel Advertising Subtotal: | $ |
| Diversity Recruitment Advertising Subtotal: | $ |
| Advertising Campaign Total: | $ |
| Payment |
| Method of payment: | |
| Purchase Order Number: | |
| Payment Purchase Order FEIN: | |
| Name on Credit Card: | |
| Credit Card Number: | |
| Credit Card Expiration Month: | |
| Credit Card Expiration Year: | |
| Credit Card Type: | |
Agree to Terms:
Mailing Instructions
If you are mailing this form with your check/purchase order,
please sign this form below and return it with your full payment to:
Attn: Marketing Department
The AvScholars Network Foundation
8526 S. Drexel Ave.
Chicago, IL 60619
| Signature: | __________________________________ |
| Date: | ______________________________________ |
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