Electrolux E-Form

First Name: Last Name:

Region: Cell Phone Number:

Date Ordered: Ship Date:

Type of Media: Quantity Needed:

Paper Color: Ink Color:

Send proof by:E-mail or Fax number:

Sale Ends Date

If choosing a multi-model layout:
Please choose where the image goes and be sure the dollar
amount and money saved corresponds with the model location.

Model #Location $ Amt Location $ Saved Location







Headline:

Dealer Info:

The information below will be printed on the media. If you DO NOT
want one or more of the items on the media DO NOT fill it out.

Store Name:Store Address:

City:State: Zip Code:

Additional Comments

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