Date: ____________________________  Client or Subscriber Number: _________________________________

New request: __________________ Deadline date/ ____________________time/ _______________

First Name: __________________________ Last Name: ___________________________________

Company Name: __________________________________________________________________

Address: _________________________________________________ City: ___________________

State / Province: ___________ Zip / Post Code: _____________________ Country: _______________

Phone No: ( ____ ) _________________________ Fax No: ( _____ ) ________________________

E-mail: ___________________________________________ Other: _________________________

Preferred Color Slides: ______________________________________________________________ 

Medium High-Res. Scan ( ___________________________ Meg ) Photo CD: ___________________

Usage Type:

Advertising: ___________ Textbook: ____________ Brochure: _______________ Editorial: ________

A/V: __________________ Electronic: ___________________ Corporate/Industrial: ______________

Other specify: _____________________________________________________________________

Size:1/4 Page: __________ 1/2 Page: ____________ Full Page: ____________ Cover: ____________

Other:___________________________________________________________________________

Distribution:

Local:________ Regional: _______ National: ______ International:___________

Specify Area: ____________________________________________________

Rights:  One-Time Use:_____________ Other: ___________________________

Print Run:__________________ Length of Time: _________________________

Model Release Needed?                              Yes: _____ No: _____

Has Image Been Used in a Computer?     Yes: _____ No: ______

Is a Fax of Layout Herewith?                          Yes: _____ No: _____

Will a Credit Line be Used?                            Yes: _____ No: _____


Method of Payment:

Type of Credit Card : ____________ Holder's full name : __________________________________

Card number : _________________________________  Exp. date : _______________________

Western Union - Money transfer control number : _________________________________________ 

Money Order by :________________________________________________________________ 

Entry details: ___________________________________________________________________

Images Numbers: _______________________________________________________________

_____________________________________________________________________________

Total Number of Images: ___________ Total Amount: $ ___________ Prepaid shipment: $ ________

Signature: _________________________________ Date: ___________ In: __________________

Print out and fill out the form, and by e-mail to: FEI - Photos  (This form must be signed.)
Sign Terms & Conditions and it  must be attached to your Order Form.
 
To confirm your shipment or order call: (705) 745-5770