Thank you.

Contact Information
Title:	Dr. Honorable Miss Mr. Mrs. Ms. Rev.
First Name:
Last Name:
Company:
Address 1:
Address 2:
City:
State:	Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Postal Code:
Country:	Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador England Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadaloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island, McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Runion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent Samoa San Marino So Tom and Prncipe Saudi Arabia Select Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Fortuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe

How should we contact you ?
Work Phone:
Fax Number:
Email Address:

Mail Piece Information
When do you want to mail?	Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Do you need help with design and printing?	Yes   No
What is the mailing QUANTITY?
Do you need a mailing list?	Yes   No
How will the mail list be provided?	On Disk: ASCII comma delimited or Excel file(Conversion fee applies for Excel files)  Via Email or FTP site: ASCII or Excel file  On tape: 1600 or 6250 BPI  Pre-Printed labels - Please comment below
If Pre-Printed labels: (select all that apply)	1UPS  Cheshire  PiggyBack  Laser  Labels are in ZIP CODE order
Other Mail List Delivery Description
What type of piece are you mailing? Check below if applicable: (select all that apply)	Selfmailer: not larger than 6 1/8 H x 11 1/2 W (Note: Not be thicker than 1/4")  Selfmailer: larger than 6 1/8 H x 11 1/2 W  Postcard: Smallest size = 3 1/2 x 5  Postcard: Largest size = 4 1/4 x 6 (First Class)  Catalog - Please comment below  #10 Envelope  6 x 9 Envelope (non-window)  Oversized Postcard - greater than 4 1/4 by 6  Monarch Envelope
Number of inserts
If Catalog, dimensions & # pages
If applicable, please specify the piece that will be imaged to show through the window envelope.
Please describe your mail piece if defferent than above:
Describe the inserts (components) that mail inside the envelope
Are you mailing one version or are you testing more than one version? Please specify.
Box or Tube: Please specify dimensions and inserts/components:
Please include any special characteristics of your mailing
Choose your mailing rate	Presort Standard (formerly BULK RATE)  First Class Presort  Priority Mail  First Class
Are you an authorized Nonprofit mailer?	Yes   No
Choose the data processing needed to improve your mailing list (select all that apply)	CASS certification - Standardizes addresses in a post office compatible format.  Merge/Purge (get rid of duplication)  NCOA (changes addresses for the people that have moved)Please allow 3-5 business days
Other - Please Specify
Tabs or Wafer Seals (applicable to selfmailers)	Affix one tab   Affix two tabs
Postage - you need to choose how its applied...(Note: Postage is due a minimum of one day in advance of mail date)	Use our indicia  Use your own indicia  Live stamps  Meter
Leftover materials are:	Recycle  Shipped via UPS  Call for customer pick up.
Return to stock for future mailing (storage fee may apply) Specify when:	Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010