Docstoc
EXCLUSIVE OFFER FOR DOCSTOC USERS
Try the all-new QuickBooks Online for FREE.  No credit card required.

consumer mailing list

Document Sample
consumer mailing list Powered By Docstoc
					                          DCMS Mailing List Policy and Agreement
                                       (Please print or type information)

1. Requestor shall utilize the DCMS mailing list for a one-time use only in accordance with the policy listed herein.

2. Requestor may not reproduce, market, or otherwise distribute the mailing list without the prior written consent of
DCMS.

3. Requestor must obtain written authorization from DCMS to utilize the mailing list for the purpose of promoting,
marketing, or advertising of magazines, flyers or literature that are not published or sponsored by DCMS.

4. Requestor must obtain written authorization from DCMS to utilize the mailing list for the purpose of promoting,
marketing, or advertising of products, drugs, or medical equipment.

Purpose of mailing list:________________________________________________________________
                          (Please return this form with a sample of your mailing piece.)

Fees for Members, Hospitals, or Medical Related Entities:
                     $150 for entire mailing list + tax .07%
                      $75 up to twenty specialties + tax .07%

Fees for Business Houses Non Medical Related:
                      $300 for entire mailing list + tax .07%
                      $150 up to twenty specialties + tax .07%


This Agreement made between the Duval County Medical Society (DCMS) and

_____________________________________________________________ (Organization)

Signature of Requestor: __________________________________ Date ___________________

Print or type name of Requestor: ___________________________________________________



          Please mail or fax this Agreement and Mailing List Request Form with Payment to:
                                     Duval County Medical Society
                                         Attn: Deana Hadden
                              555 Bishopgate Lane, Jacksonville, FL 32204
                                 Phone 355-6561 Ext 106 Fax # 353-5848


            Approved by DCMS             Disapproved by DCMS            *for use by DCMS only*

                                Duval County Medical Society
          Signature: _____________________________ Date: _______________________
                                                 555 Bishopgate Lane
                                       JACKSONVILLE, FL 32204
          Name & Title____________________________________________________
                                     904 355-6561 ext 106 FAX # 353-5848




                                                                                                     Updated May 2008
                     DUVAL COUNTY MEDICAL SOCIETY
                      MAILING LIST REQUEST FORM
                                    Please Type or Print Clearly

Date: _____________                Delivery Date Requested: _______________________
Name or Organization: _______________________________________________________
Attention: __________________________ Email:_________________________________
Address: ___________________________________________________________________
City: ____________________________________ State: _____ Zip: _________________
Telephone: ____________________________ Fax: ________________________________

                   ***Mailing Lists are Available in Electronic Format Only***

I.     Format: E-mail Only (Excel, ASCII format, comma delimited text)
         If different than above, email to: ______________________________________

II.    Distribution
        Entire DCMS Membership (Includes retired)
        Active Only
        Specialty Specific:
          List each specialty ____________________________________________________
       _______________________________________________________________________
       _______________________________________________________________________
       Note: Names and addresses will be office only unless approved for the home mailings

III.   Purpose (attach sample of mailing piece)
        Professional Announcement-specify
        Seminar or Meeting Announcement
        Other- please specify: __________________________________________________

IV.    Payment:           ***** (List Provided Upon Pre-Payment Only)*****
        Check (enclosed)  Credit Card circle type: (Amex Discover Mastercard Visa)

Credit Card #: ________________________________________________Exp. Date: _______

Name as it appears on Credit Card________________________________________________

Card Billing Address ___________________________________________________________
                    (If different than above)


             Fax to 353-5848 or Mail (address above) to: Mrs. Deana Hadden


                                                                                      Updated May 2008