Requested date of publishing :                                    Year      Month       Day   

 I am enclosing or sending the text and the logo to be published.:
      Text max 140 letters, logo max 40 KB
 surface mail     fax
 e-mail, document attached to e-mail  
Product text as follows!
Product text, please attach here:

Company                                                              Department                    Contact person
           

Street                                                No.

City                                 ZIP         Country
     
Phone                           Fax
  
E-mail