Lead Concepts Mailer Code(s):________________________________

Number of pieces to be mailed:________________________________

Demographic selections: Specify: Age range_________________ Income range_________________

Geographic selection, by zipcode (list in order of preference / all zipcodes possible to avoid and conflicts or shortages)

Mailing Cost:
To calculate the cost of your mailing, multiply the quantity to be mailed by the cost per thousand price list.

Quantity Ordered X Cost Per Thousand

If Using a Credit Card: Card #_______________________________________________Exp ___________________

Card Holders Name__________________________________Signature____________________________________

Call Toll Free 1-800-283-0187 or Fax to: 1-800-238-0140