The Temple: Bulletin Ad Form
POINT CONTACT INFORMATION
Salutation
Please select...
Mr.
Mrs.
Ms.
Dr.
Miss.
Rabbi
First Name
Middle Name
Last Name
Email
Phone
Address
City
State
Please select...
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
VI
WA
WV
WI
WY
Zip
BUSINESS INFORMATION
Business Name
Business Web Address or Email
Will be used for hyperlink on website
Different Address from above?
Please select...
No
Yes
Work Address
Work City
Work State
Please select...
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
VI
WA
WV
WI
WY
Work Zip
ADVERTISEMENT INFORMATION
Type of Advertisement
Please select...
Small box in color: $650/year
Medium rectangle box in color: $1000/year
Large square box in color: $1,800/year
Upload Artwork, Logo, or Business Card
Notes about Advertisement
PAYMENT INFORMATION
Start Date
End Date
Amount
$
Adjustment?
Please select...
No
Yes
Adjustment Amount
$
Total with Adjustment
$
I would like to pay by
Please select...
ACH/eCheck in Full
Credit Card in Full
Mail a Check
I'd like to cover all transaction fees so 100% goes to The Temple
Please select...
Yes
No
Transaction Fee
$
New Total
$
Year
Credit Card has an automatic 2.5% transaction fee added
Credit Card Billing
Credit Card No.
Security Code
Exp. Month
MM
x
Exp. Year
YYYY
x
Billing Street
Billing City
Billing State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Billing Zip Code
Billing Country
ACH/eCheck Information
Bank Routing Number
Bank Account Number
Bank Account Type
Please select...
Checking
Savings
Bank Name
Account Holder Name
How did you hear about this opportunity?
Temple App
Temple Bulletin
Temple Mailing
Temple Member
Community Newspaper
Email
Facebook
Flyer
Google Search
Questions or Comments?
HIDDEN FIELDS
ContactID
AccountID
AdID
Gateway Total Amount
$
Gateway Amount
$
Gateway Frequency
Fee
Mobile?
Yes
Size
Authnet_Hidden_Fields
Contact Information