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INSERTION ORDER FORM

Niemczyk Hoffmann Group, Inc.

Personal Information
Name: Company:
Address: City: State: Zip:
Phone: E-Mail:
Advertising Options
PennTrux Ad Size: Frequency: Ad Rate:
Months to Run:
Jan Feb March April May June July August Sept Oct Nov Dec
The Barrister Ad Size: Frequency: Ad Rate:
Months to Run:
February May August November
Medical Record Ad Size: Frequency: Ad Rate:
Months to Run:
March June September December
Fitness Berks Ad Size: Frequency: Ad Rate:
Months to Run:
January April July October
One Ad Size: Frequency: Ad Rate:
Months to Run:
March June September December
Wedding Planner Ad Size: Frequency: Ad Rate:
Comments/Special Instructions
Payment Information
Credit Card (Mastercard or Visa only) Check
Credit Card #: Exp. Date: CSV:
Cardholder: Signature:

Make checks payable to: Niemczyk Hoffmann Group, Inc.

Mail: Niemczyk Hoffmann (Publisher), 117 Philadelphia Avenue, Shillington, PA 19607

Fax: (610) 685-0916 | Questions: (610) 685-0914

Please Read Carefully Before Signing

I understand placement of my insertion order does not guarantee the order and page location of advertisements. All contracts are non-cancelable.

Payment Policy: Advertisers & advertising agencies are jointly responsible for payment of all insertions. Publisher will invoice the agency or advertiser upon publication mailing. Publisher will provide printed proof of insertion. Payment must be received within 30 days of invoice or finance charges of 1.5% will be incurred. In the event that it becomes necessary for the Publisher, at its option, to place this agreement in the hands of an attorney or collection agency for debt collection, the advertiser agrees to pay attorney fees and all costs incurred by the Publisher.

The advertiser or the agency will bear full responsibility for withholding advertising materials that may violate any law, regulation or ruling of the Federal Trade Commission or infringe on any copyright, trademark or patent and shall defend, identify and hold harmless the Publisher from all third party claims on account thereof. Publisher reserves the right to reject any advertisement, photograph or illustration that is not deemed to be acceptable in keeping with standards of the publication.

I acknowledge upon signing this contract by electronic verification, that I have carefully read and accepted the terms, condition and policies of this contract. I further understand that any verbal agreements are not binding to this agreement.

Certification

My signature and initials below certify that the information in this application is true, accurate and complete.

  
© 2012 Niemczyk Hoffmann Group, Inc. :: 2921 Windmill Road, Suite 4 • Sinking Spring, PA • 19608 • 610-685-0914
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