Please write or type clearly:

Cardholder Name________________________________________

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Credit Card Number

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Exp. Date

___ ___ ___ ___ ___         Signature _________________________________________
P.O. Box or Street number
where credit card is billed.
                                                                                                      Amount  $_________ ._____
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Zip Code

FAX with ad copy to: (435) 259-6918

Or: MAIL with ad copy to: The Ad-Vertiser   P.O. Box 1323, Moab, Utah 84532
If you prefer not to have your card # entered on this form, you can phone it in separately. Your ad, or
other purchase, will be held until confirmed by phone. All information is required by our banking system
(in the absence of actual credit card) to complete this transaction. Thank you for advertising with us!