List Order Form

INVESTORPLACE MEDIA, LLC
LIST MARKETING
9201 Corporate Boulevard, Rockville,  MD 20850
Phone (601) 620 4135 | Fax (703) 940 7749

LIST ORDER FORM

1. Complete the sections below  3. Attach a sample mail piece.
2. Sign List Rental Agreement   4. Mail Attn: Mike Ferry or Fax (703) 940 7749

Customer P.O. No. _____________ Date Needed _____________ Maildate _____________

 List Required                 Price/M       Selections             Quantity

1.___________________________ $____________ ______________________ ____________

2.___________________________ $____________ ______________________ ____________

3.___________________________ $____________ ______________________ ____________

4.___________________________ $____________ ______________________ ____________

5.___________________________ $____________ ______________________ ____________

Special Instructions: _______________________________________________________________

_____________________________________________________________________________________

____________________________________________________  SHIP VIA ______________________

SHIP TO _____________________________________ FORMAT ___ Magnetic Tape ________ BPI
                                                     ___ Email (we need email address)
_____________________________________________        ___ Cartridge
                                                     ___ CD
_____________________________________________        ___ Keycode On Labels __________

_____________________________________________ PACKAGE ID ____________________________
  Shipping & Handling Charges Will Be Added

___ Prepayment        Amount $____________      Proforma Invoice will be faxed to you.
    (First time mailers must prepay)

NAME _______________________________________ PHONE (_________) ________-_____________

COMPANY ____________________________________ FAX (_________) __________-_____________

ADDRESS ____________________________________ Signature ______________________________

____________________________________________ Date ______/______/______