CLIENT CONTACT INFORMATION	SERVICE REQUESTED
CLIENT	H2-A	H2-B
CONTACT	SUPERVISED RECRUITMENT
ADDRESS
CITY	ST	ZIP	PERM (Non-Professional)
PHONE	FAX	2 SUNDAY NEWSPAPER ADS
EMAIL	PERM (Professional)
BENEFICIARY FIRST NAME	BENEFICIARY LAST NAME	2	2 SUNDAY NEWSPAPER ADS, OR
EMPLOYER	REFERENCE	1 SUNDAY NEWSPAPER & 1 TRADE JOURNAL AD
BILLING DETAILS	+	AND 3 OPTIONS FROM BELOW
ORDERS WITH INCOMPLETE BILLING INSTRUCTIONS WILL NOT BE ACCEPTED	3	Employer’s Website	Job Search Web Site ***
BILL ATTORNEY	BILL EMPLOYER	Local / Ethnic Papers	Campus Placement
PRE-PAYMENT (For Attorney / Employer Only. We Do Not Accept Payment From Beneficiary)	Trade / Prof Organizations	Radio Ads
COMPANY	JOB SEARCH WEBSITE ***
ATTENTION	CITY:	ST:	ZIP:	EMAIL:
ADDRESS	Less Than HS	HS / GED	Some College	Vocational School
CITY	ST	ZIP	Associate Degree	Bachelor’s Degree	Master’s Degree	Doctoral Degree
PHONE	FAX	Intern / Entry Level (0 – 2 YRS)	Mid-Career (2 – 15 YRS)
EMAIL	Senior (15+ YRS)	Executive (SVP/EVP/VP)	Not Provided
CREDIT CARD	ACTION REQUESTED
VISA	MasterCard	AmEx	Discover	MEDIA RESEARCH (Ad WILL STAY ON HOLD until we receive signed approval)
CARD#	CCV CODE	EXPIRY	PRICE QUOTE
NAME	ABBREVIATE AD TEXT
I AUTHORIZE ADNET TO CHARGE THE CREDIT CARD ABOVE	PLACE AD
MEDIA (NEWSPAPER, MAGAZINE, PROFESSIONAL PUBLICATION, TRADE JOURNAL, INTERNET)	ASSOCIATED WEB	INSERTION DATES / NOTES
1	YES	NO
2	YES	NO
3	YES	NO
AD TEXT (PLEASE TYPE AD TEXT. HANDWRITTEN OR SCANNED TEXT WILL NOT BE ACCEPTED)
PERM CHECKLIST (ALL FOUR ITEMS OF THIS CHECKLIST ARE REQUIRED. MISSING INFORMATION WILL ONLY DELAY THE PROCESSING OF THIS AD)
JOB TITLE	JOB LOCATION (DIFFERENT FROM RESPONSE ADDRESS)	NAME OF EMPLOYER	RESPONSE INFORMATION