Date: ___________
Latin Times Rep: _________
Request for Service/Payment Form
Client Name: _____________________________ Title: ___________________________
Company Name: _________________________ RSVP Package Name: _____________
Business Address: __________________________ Phone: ________________________
City, State: _____________________________Fax: ______________________________
Web Address: _______________________ Email Address: ________________________
Type of Business: _________________________________________________________
Description of Service:______________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Do you require Graphic Design? ________ Graphic Design is not included in rates.
If you require Graphic Design, please include design materials, editorial, product and contact
information: ______________________________________________________________
________________________________________________________________________
________________________________________________________________________
All services must be pre-paid.
Credit Card and other Payment Information
Want to pay by e-Check? Make out your check to Latin Times Media, Inc., take a picture of th