Please print this form, fill it out and mail or fax to:
Electronic Communication Systems
1295-A Highway 51 Bypass
Dyersburg, TN 38024
(Phone: 731-285-5936)(Fax: 731-285-2240)
Please print clearly!
| Name: |
| Company: |
| Address: |
| City, State, Zip: |
| Phone: |
| Fax: |
| Contact: |
| Setup Fee: | $ |
| Publishing Advance: (yearly, semi-annually, monthly) | $ |
| Contract Period: (year, six month, monthly) | $ |
| Options/Extras: | $ |
| Rush Order: | $ |
| Total: | $ |
I agree to pay the aforementioned fees in advance.
Authorized
Signature:___________________________________Date:_____________________