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Request for use of Radio Ad and Media Buy Form

Simply select the target audience radio ad you want to use ("recently retired" or "empty nester"), complete the "Request for Use of Radio Ad and Media Buy" form below and click "submit." A representative from Burgess Media will contact you within 48 hours to assist you with the recording, placement and purchase of your radio advertisement. Please note that there is no charge to you for the services of Burgess Media – your only cost will be the cost to place the radio ad for airing on the radio station.

Fields marked * are required

Date Requested : 06-19-2013

Radio Ads - 0:30 Seconds

Select a Radio Ad * --Select-- Empty Nester Recently Retired

Contact Information

Name *
Club Name (if applicable)
Club Number (if applicable)
ACBL Member No. *
Phone No. *
Email *

Media Buy Information

City(s)/State(s) where you want this Radio Ad to be aired
City
State/Province	--Select-- Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland and Labrador North Carolina North Dakota Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon
Additional City
Additional State/Province	--Select-- Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland and Labrador North Carolina North Dakota Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon
Dates and Times to Run the Radio Ad (if no preference, recommendations will be provided to you)
Date/Date Range (ex. June 1, 2010 or for date range - June 1 - 21, 2010)
Time you desire Radio Ad to Run : (be sure to designate a.m. or p.m )
Target Audience (Autopopulate upon Radio Ad selection)
Tag Line - 0:05 seconds
Your Club/Bridge class name to be used in Radio Ad Tag Line *
Phone Number to be used in Radio Ad Tag Line *
Radio Stations Preferred (if no preference, recommendation will be submitted)
Planning Budget: (Ex: 1000.00 )	$
Payment Options * (If payment is made by invoice, must be paid in full prior to air time)	Visa Invoice
Additional Notes:
Type the word (Leave no spaces between the letters)