2020 TOP DOCTORS PLAQUE ORDER FORM Show your clients how much Northern Virginians value you and your practice. Order yours today! Please answer the following (print neatly to ensure accuracy) and mail or fax this form and your payment to Northern Virginia Magazine (Plaques), 14901 Bogle Drive, Suite 307, Chantilly, VA 20151 Fax: 703.288.0203. For questions or concerns please email us at [email protected]or call 703.230.3812. Phone 703.288.0204 | Fax 703.288.0203 www.NorthernVirginiaMag.com TO ADVERTISE CALL 703.230.2980 OR EMAIL ADVERTISING@ NORTHERNVIRGINIAMAG.COM OFFICIAL BADGE to use for your Website or Advertising Plaque Information Name (& Credentials) of Top Doctor winner to appear on the plaque Specialty (Optional) Practice Name (Optional) Number of Plaques ordered ($169 each) Total ❒ If you would like to receive a complimentary digital version of your plaque for use on your website, please check here Plaque Approval You will be required to approve the plaque prior to production. Please provide contact details below of who the proof should be sent to: Name Phone Email Billing Information Method of payment: Credit Card Number CVV Expiration Date (Month/Year) Name as it appears on the card Billing Address: (Address, City, State, ZIP) Shipping Address Atten: Shipping Address: (Address, City, State, ZIP) *no P.O. Boxes PLEASE CHECK IF YOU ARE INTERESTED IN ADVERTISING ❒ Thinking about advertising and would like rates sent over to me via email. ❒ ❒ ❒ the only OFFICIAL PLAQUE Plaques sold by third parties are unauthorized and infringe Northern Virginia Magazine’s registered trademark. Northern Virginia Magazine is the only source for official “NorthernVirginia ® Magazine Top Doctors” plaques. ®
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2020 TOP DOCTORS PLAQUE ORDER FORMShow your clients how much Northern Virginians value you and your practice. Order yours today!Please answer the following (print neatly to ensure accuracy) and mail or fax this form and your payment to Northern Virginia Magazine (Plaques), 14901 Bogle Drive, Suite 307, Chantilly, VA 20151 Fax: 703.288.0203. For questions or concerns please email us at [email protected] or call 703.230.3812.
Name (& Credentials) of Top Doctor winner to appear on the plaque
Specialty (Optional)
Practice Name (Optional)
Number of Plaques ordered ($169 each) Total
❒ If you would like to receive a complimentary digital version of your plaque for use on your website, please check here
Plaque ApprovalYou will be required to approve the plaque prior to production. Please provide contact details below of who the proof should be sent to:
Name
Phone
Email
Billing Information
Method of payment:
Credit Card Number CVV
Expiration Date (Month/Year)
Name as it appears on the card
Billing Address: (Address, City, State, ZIP)
Shipping Address
Atten:
Shipping Address: (Address, City, State, ZIP) *no P.O. Boxes
PLEASE CHECK IF YOU ARE INTERESTED IN ADVERTISING❒ Thinking about advertising and would like rates sent over to me via email.
Approval Code: Sales Rep: Date Processed: Invoice#
❒
❒ ❒ ❒
PLEASE CHECK IF YOU ARE INTERESTED IN ADVERTISING:Thinking about advertising and would like rates sent over to me via email.
Name Phone
Email
Credit Card Number Expiration Date
Name as it appears on the card
Billing Address: (Address, City, State, ZIP)
Atten:
Shipping Address: (Address, City, State, ZIP) *no P.O. Boxes
Name of Top Financial winner to appear on the plaque Quali� cations/Certi� cations (Optional)
Company Name (Optional)
Number of Plaques ordered ($169 each) Total
If you would also like to receive a complimentary digital version of your plaque for use on your website, please check here ❒
$
/
Method of payment:
OFFICIAL 2015 TOP FINANCIAL PLAQUE ORDER FORMPlease answer the following (print neatly to ensure accuracy) and mail or fax this form and your payment to Northern Virginia Magazine (Plaques), 14104 Newbrook Drive Chantilly, VA 20151 Fax: 703.288.0203. For questions or concerns, please email us at [email protected] or call 703.288.0204.
Plaque Information
Plaque Approval
Billing Information
Shipping Address
You will be required to approve a proof of the plaque prior to production. Please provide contact details below of who the proof should be sent to:
the only
OFFICIAL PLAQUEPlaques sold by third parties
are unauthorized and infringe Northern Virginia Magazine’s
registered trademark. Northern Virginia Magazine
is the only source for official “NorthernVirginia® Magazine