Live Work Play: Print - Special Section (Already Signed)
Agreement Date
(Required)
Please indicate the date this Agreement is being created on
MM slash DD slash YYYY
Sales Associate
(Required)
Please select the Sales Associate for the Advertiser
Select From Dropdown
Stephanie Sullivan
Michele Schuermann
Diana Brush
Kim Hunter
Patrick Reynolds
Leslie Ogle
Chelsea Bren
Mamie Lee
Justin Ckezepis
Sales Associate's Email
(Required)
Please indicate your Sales Associate Email - this is required for eSignature
Name of Business Advertising
(Required)
Please include the Business Name of the Advertiser
Business Physical Address
(Required)
Please include the Business Address for the Advertiser. If no physical address, please use the Advertisers Billing Address.
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Individual Contact Name
(Required)
Please include the individual contact for the Advertiser
First
Last
Contact's Best Email Address
(Required)
Please include the email for the individual who will be signing on behalf of the Advertiser - this is required for eSignature
Contact's Best Phone #
(Required)
Please include the advertisers best contact Phone Number
Alternative Phone #
If provided, please include an Alternate Phone Number
Location Selection
(Required)
Please indicate which Location(s) this Live Work Play Advertisement should be in
Huntersville
Cornelius
Davidson
Mooresville
Troutman
Statesville
Denver
Category Selection
(Required)
Please indicate which Category this Live Work Play Advertisement should be placed as
Auto Care
Child Care
Health Care
Home Service
Professional Services
Restaurants/Entertainment
Pet Care
Self Care
Leisure & Travel
Shopping
Payment Method
(Required)
Please select the Payment Option you prefer for us to have on file for your Campaign
Credit Card or ACH?
Credit Card
ACH Electronic Bank Transfer
Name on Card
(Required)
Please include the Name as it appears on the Credit Card
Credit Card Number
(Required)
Please include the full Credit Card Number
Expiration Date
(Required)
Please include the Expiration Date of the Credit Card. Please format as MM/YY
CCV
(Required)
Please include the 3 or 4 digit CCV code shown on the card
Billing Zip Code
(Required)
Please include the Billing Zip Code for the card
ZIP Code
Name Listed on Account
(Required)
Please indicate the appropriate Name listed on the Bank Account
Address Listed on Account
(Required)
Please provide the appropriate Address listed on the Bank Account
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Account #
(Required)
Please include the Bank Account # that should be used for the ACH Bank Draft
ABA Routing #
(Required)
Please included your bank's ABA Routing #
Campaign Start Date
(Required)
Please indicate the Print Issue first run date. Please select the first day of the month as the day of the month of the Issue
MM slash DD slash YYYY
Campaign End Date
(Required)
Please indicate the Print Issue last run date. Please select the last day of the month as the day of the month of the Issue
MM slash DD slash YYYY
Monthly Campaign Total $
(Required)
Please indicate the Total Monthly Campaign Fee for this Campaign including all selected Locations that will be billed each month. This DOES NOT include any Add-Ons
General Notes
(Required)
Please include any Notes that are relevant to this Advertising Agreement
Please upload the Signed Agreement for this new Live Work Play order.
(Required)
Accepted file types: pdf, Max. file size: 50 MB.