National Hispanic Corporate Achievers, Inc.
SpeakOut TV Advertising/Marketing Program Reservation Form

 
Company: Contact Name:
Address:
City: State: Zip:
Phone: Fax: E-mail:
Yes, I wish to participate in the SpeakOut TV Advertising/Marketing program
  • Cost $350.00/month. Total cost for one year of services: $4,200.00
    • Submitting this form acknowleges that National Hispanic Corporate Achievers can charge $350. per month on the submitted credit card number for one year beginning on the date the form is submitted and every 30 days thereafter to cover the costs of this advertsing program.
    Amount to be Paid: Authorized Agent:
    Please fill out the credit card information to charge the amount authorized.
    Visa Master Card American Express
    Name on Card:
    Mailing Address of Card:
    City: State: Zip:
    Card Number:
    Expiration Date:
    Last 3 digits on back of card:
    Print Authorization Name:
    Email of Card Holder:
    Special Instructions:

    		Hispanic Achievers
    P.O. Box 160912
    Altamonte Springs, FL 32716
    Phone: 407-228-7267 or 321-356-5596