Batanga University Distribution Form

Thank you for your interest in being one of our magazine’s distributors. In order to begin receiving shipments, please fill out the basic information below. We will contact you from time to time to provide you with updates and inquire about any special needs or requests you may have. Muchas gracias!

Bold fields marked with a * are mandatory.

Name of School*
Department or Organization*
Contact First / Last Name*
Address (no P.O. Box)*
City * State* Zip*
,
Phone 1 (digits only)* (area code + 7-digit number)
Phone 2 (digits only) (area code + 7-digit number)
E-mail*
Re-enter your e-mail address*
# of magazines you would like to receive


4000 5000
How many of our magazine racks do you currently have on campus?*
(racks fit approximately 500 magazines each)









How many of our magazine racks do you need (if any)?*
(racks fit approximately 500 magazines each)









Where on campus do you plan to distribute our magazine? (check all that apply) *











Date Submitted: 08/28/2008
Date of Expiration: 08/28/2011
To your knowledge, will you be the recipient of our magazine up to and including the expiration date above? (check one below)
Confirm:*



If no, please provide contact information below for an additional contact at your school (if available):
Alternate First / Last Name:
Alternate E-mail:
Alternate Phone: (digits only)
Yes, I agree to distribute Batanga University Magazine :*



To verify your request, please provide us with your month of birth:*