Ordered By:		Ship To: (if different than ordered by)
Name		Name
Title		Title
Organization		Organization
Street Address		Street Address
Address (Cont.)		Address (Cont.)
City		City
State/Province		State/Province
Zip/Postal Code		Zip/Postal Code
Country		Country
Phone		Phone
FAX
Email Address
Offer
Mail Date

*Please send a sample mailing piece or telemarketing script for all response & subscriber lists.

NAME OF LIST	Order Quantity

Please complete and submit below, fax, or mail, to ACT ONE.
A representative will contact you with the total cost of your list order.

Base Price:

Base Price - One Time Use

Base Price - One Year Unlimited Use

Additional Selections:

Category
Business Contact Name
Telephone Number
FAX Number
Employee Size
Sales Volume
Executive Function/Title
Specialty Function/Area
Teacher/Professor Specialty
Primary or Secondary SIC Code
Headquarters/Branch Location
New Business
Demographics...Age/Income/Gender/Etc.
Ethnicity
Home Address
Title Addressing
Key Coding
Carrier Route Pre-Sorting
Split Charge
Merge Charge
Bar Coding/Bag Tags
Other Selections

Geographical Selections:

Entire U.S.
Nth Select
States/Provinces	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 Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territory Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
SCFs
Zip/Postal Codes
Counties

Formats:

Cheshire Labels

Pressure Sensitive Labels

Magnetic Tape/Cartridge

Disk IBM 3.5"

CD Rom

Sheet Listing

3 X 5 Index Cards

E-Mail Transfer

Modem Transfer

Shipping/Handling:

Standard 2-Day Delivery Minimum

Overnight Delivery Minimum

Payment Method:

Company Purchase Order #
Credit Card	Please Select Card Type VISA MasterCard American Express Discover
Cardholder Name
Billing Address
Billing Address (Cont.)
Card Number
Expiration Date

Please note: Payment terms are net 30 days from the invoice date to customers with a continuing use of our services.  Prepayment deposit may be required on any order and is always required on the first three (3) orders from new clients.  Accounts may be opened upon approval by our credit department.   Business or personal checks, money orders, as well as MasterCard, Visa, American Express, and Discover credit cards, are accepted.

Having trouble filling out the form?   Contact us at (800)ACT-LIST (228-5478), or fill in and submit your incomplete form and an ACT ONE LISTS representative will call you with the information you need!