Contact Person - Placing This Order: *

First Name

Last Name

Mailing PO and/or Street Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number (days): *

(###)

###

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Phone Number (evenings or cell)

(###)

###

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Your Cheshiremen Rep/Member:

First Name

Last Name

CONTENTS / Logo - Text - Artwork *

Select one:

Repeat 1: Run my previous Cheshiremen Program AD with NO changes.

Repeat 2: Run my previous Cheshiremen Program AD with changes that I will submit.

New 1: New Customer, New Ad - I'll submit via email or Rep.

New 2: Prev. Customer, Please use NEW artwork that I will submit.

Other: (explain below)