[from Kenan: I plan to redo this form for design and branding. Maybe it could be a mail form.]

DYNAMIC MEDIA IN TRANSITION

PBI Media, LLC

701 Westchester Avenue

White Plains, NY 10604

(Please fill out coupon completely and mail to the above address)

 

_____ Number of Books ordered @ $65 ea. plus $5 S&H

For quantities of 5 or more, please contact publisher at 800-800-5474, x3082

 

____________________________________

First  Name                                                         Last Name 

______________________________________________________________

Company

______________________________________________________________

Street Address

______________________________________________________________

City                                                           State                     Zip

 

Please provide your phone number and e-mail address in case we need to contact you:

 

        Daytime Phone:  ccc-ccc-cccc

 

        E-Mail Address: _____________________________________

 

Method of Payment:

  c Check or Money Order enclosed (Sorry no CODs)

  c Visa     c MasterCard     c American Express

 

cccccccccccccccccccc

Credit Card Account Number

                                                                                      cc   cc

Signature: _______________________________       Expiration Date