EmailMe Form - REMOTE BROADCAST ORDER

Name of Business *

Person who approved order *

First Last

Business Email

Account Rep *

Account Rep Email

Date of Remote

MM / DD / YYYY

Length of Remote

Remote Start Time

Remote End Time

Lead Talent

First Last

Station Staff that will be there

Are we providing prizes or giveaways?

Are we providing food and drinks?

If we are providing prizes, food and drinks, or anything else, detail that below. What are we cooking, who's cooking, who's serving. Will it be sit down or do we need a buffet line. If customer has made special requests, detail that here as well.

Account Information

Billing Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Remote Location Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Checkbox

$795-Basic 2 hour remote (includes 60 ads on 3 stations to promote remote)

$150-Additional hours ($150 per hour, add that in the section below.)

$500-Prize Pack (Tshirts, tickets, etc.)

$300-Hot Dogs and water for 150 people

$750-Pulled Pork for 150 people

$150-Sodas for 150 people

Any additional add on's or special pricing, detail here.

Total cost of remote

Station Remote will broadcast on

Run 60 Promo ads on: (choose 3, unless more are approved)

Start airing promo ads

MM / DD / YYYY

Stop Running promo ads ----------- (put a stop time!)

MM / DD / YYYY HH : MM AM/PM

Voice on Promo ad

Any additional details. Comments, or suggestions to improve this form.

CC Information

Remotes are pay in advance, have you collected the money for this order?