Advertiser's Name

First Name

Last Name

Advertiser's Email Address

Advertiser's Phone

(###)

###

####

Name on Credit Card

First Name

Last Name

Credit Card Number

Credit Card Type

Visa

Mastercard

Expiration Date

BILLING ZIP CODE

Dancer's Name

If Applicable

First Name

Last Name

Ad Size

Quarter Page $25

Half Page $50

Full Page $100

Grand Total Due:

Please write the total amount due here:

Digital Agreement

I understand that by filling out this form, I agree for Carolina Collective Dance Centre to charge my card for the above listed amount. I understand that the deadline for payment to reserve my place is 4/28/23. I also understand that my deadline to submit artwork is 5/1/23. If artwork is not submitted by 5/1/23, the ad will not make it to in the final program.

PROGRAM DEDICATIONS