Date:
Client:
Company:
Address1:
Address2:
City:
State/Province:
Zip/Post Code:
Country:
Telephone:
Fax:
Email:
Do You currently have?	A Web Site: A Banner:
Web site URL:
Banner URL:
Banner Target URL:
Type of Banner Ad account you wish to purchase: Click-thrus Monthly
Number of Impressions:
Total cost:	$
Number of Click-thrus:
Total cost:	$
AD MATERIAL:	From Advertiser BSI Generic BSI Enhanced Ad (POA)
Method of payment:	Credit Card Check
Total amount of this order:	$
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For all orders press:	OR

If payment is being made by check, simply print a copy of this completed form and send it along with your payment to:

Mail Checks to:
Buyer Services International
P.O. Box 231171
Old State House Square
Hartford, CT. 06123-1171 USA

Payments.
Advertisements must be prepaid until credit had been established with BSI. Credit will only be accepted for renewal order processing. Failure to receive payment for a renewal order five business days after renewing the order will result in removal of the advertising until payment is received. Advertising agencies placing orders for a client guarantee payment due the publisher.

Copy Acceptance.
Advertising is accepted upon approval of the publisher. The agency and/or advertiser indemnifies and holds the publisher harmless from any loss or expense resulting from claims or suits for defamation, libel, violation of right of privacy, plagiarism, copyright infringement, unfair competition, unfair trade practices, and infringement of trademarks, trade names, or patents.

Copy Responsibility or Copy Creation.
If an advertiser agrees to submit copy, the advertising copy is the responsibility of the advertiser. New copy must be received by the closing date, and copy from prior insertions will be rerun if new copy is not received by closing date.

BSI can provide a generic banner ad at no charge upon request of the advertiser. BSI at the request of the advertiser can contract to generate a banner ad with enhanced graphics, logo insertion, etc. for an additional charge. All ads created by BSI, generic or enhanced, will not be run until approved by the advertiser.

Rates and Refund Policy
Advertising will be billed at the published rates per the single submission or reduced multiple rates available. The advertiser will receive complete response reports for the amount of advertising purchased with no refunds for partial response reports. Contracts for multiple renewals are considered binding for the contracted period.

Limitation of Liability
BSI will not be responsible for any error in any advertisement published unless a copy of the advertisement is requested in writing by the advertiser and returned to BSI with such error or correction plainly noted in writing. If any error is so noted and is noted as incorrect by BSI, its liability shall not exceed a proportion of the entire cost of such advertisement as the space occupied by the advertisement during the contracted period.

Payments forwarded which contain incorrect rates or conditions agree that the advertising called for will be inserted and charged at the schedule of rates in force when payment in full is received. A failure to make an order correspond to current price or rules will be regarded as a clerical error and the advertising will be inserted when corrected.

BSI is not liable for any failure to publish or circulate all or any part of any issue because of circumstances beyond its control.