Day Ad is to Run:

Name of Individual Placing Ad:

Address:
     

City:

Phone:
      

Zip Code:

Email:
      

Relationship to Individual(s) Mentioned in Ad:

Individual(s) Age: (optional)

Type:
Free Liner Paid 2x3 $20

Ad Copy: (what ad is to say)

  I certify that the information on this form is true.   Further, I take full responsibility for the contents of the advertisement, and shall indemnify the Salisbury Post should any costs or damages of any kind whatsoever result from its publication.  I understand that my name will be disclosed to the individual(s) mentioned in the ad if requested by the individual(s).

     
   Authorizing Name