New Advertiser Account Form

New Account or a change to an existing account?

New
Change

Direct or Agency

Direct
Agency

Account # (if applicable)

ACCOUNT INFORMATION

Advertiser

Care Of/Attention

Buying Contact or Billing Contact?

Buying
Billing

You may select both if applicable.

Address

Address Line 1

Address Line 2

City

State

Zip Code

CLIENT RELATIONSHIPS: AGENCY/PARENT

Same as account information?

Yes
No

Account #

Agency Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Name

First

Last

Revenue Email

BILLING INFORMATION

Billing Cycle

Calendar
Broadcast

Name

First

Last

Email for Statements

All statements will be emailed unless mailing is approved by management.

Phone

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

EDI Code (if applicable)

CLIENT DESIGNATIONS

Account Executive

First

Last

Product Code

Revenue Code

Client Categories

Revenue Code 1

Revenue Code 2

Revenue Code 3

ADDITIONAL CONTACT INFORMATION

Name

First

Last

Phone

Email