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Company Information

* Name of Representative:  
* Title of Representative:  
* Company Name:  
* Company Address:  
* Company City:  
* Company State:  
* Company Zip Code:
* Company Phone:  
Company Fax:
Company Website:
*Company E-mail:  

It is understood and agreed that APPA reserves the right to assign advertisements to locations within the e-newsletter (CC Headlines and More) and hereby assures advertisers that APPA will make every effort to place ads in the best possible location for the benefit of the advertiser. APPA will notify the advertiser should a change in ad space be needed and will make good faith efforts to arrange ad space similar in cost and position as that originally requested.

I hereby represent that I am authorized to submit this Advertisement Reservation Contract on behalf of my company; that I have read, understand and agree on behalf of my company to be bound by the terms of the contract; that the information provided herein is true; and that I understand that this Contract is complete only when accepted by APPA.

 I have read and agree to the above.


Credit Card:
Cardholder Name:
Card Number:
Expiration Date mm/yy:
V Code:
( Visa or Mastercard: 3 digit code located in the signature line on the back of the card immediately following credit card number. American Express: 4 digit code located on front of card. )