Media Agreement

Media Agreement
Who are you? *

Sidney Jairo Miguel Gabriela Dawn Karla Brad
Purpose of this Media Agreement? *
*For the last two options, please have the existing Job Order Number ready to enter below.
Date *

Month Day Year
Date
Primary salesperson? *
Is there a second salesperson?
Client Information:
Client Name *
Client Contact *
Agency Name
Billing Contact
Address *
City *
State *
Zip *
Phone *
Fax
Mobile/Direct Line
E-Mail *
example@example.com
Billing E-Mail (If different)
example@example.com
Facebook Handle
Instagram Handle
Twitter Handle
P.O. Number
Invoice Preference *

E-Mail US Mail
Product Information:
Select all the products you would like to include on this Media Agreement:

A Newspaper Ad (or article) A second Newspaper Ad (or article) A third Newspaper Ad (or article) A Web Banner A second Web Banner A Digital Campaign or Organic Post A second Digital Campaign or Organic Post
Newspaper Ads
Newspaper Placement Requirements
Does client want digital tear sheets?

YES
Size of your Newspaper Ad 01 *
Newspaper Ad01 Color and Type *

Black & White Full Color Classified
Weekly Rate of Newspaper Ad01: *
Number of Insertions of Newspaper Ad01: *
Newspaper Ad01 Line Total: *
*auto-filled
Newspaper Ad01 Scheduling: *
Use the NOTES box below if you need more space.
Size of Newspaper Ad 02 *
Newspaper Ad02 Color and Type *

Black & White Full Color Classified
Weekly Rate of Newspaper Ad02: *
Number of Insertions of Newspaper Ad02: *
Newspaper Ad02 Line Total: *
*auto-filled
Newspaper Ad02 Scheduling: *
Use the NOTES box below if you need more space.
Size of Newspaper Ad 03 *
Newspaper Ad03 Color and Type *

Black & White Full Color Classified
Weekly Rate of Newspaper Ad03: *
Number of Insertions of Newspaper Ad03: *
Newspaper Ad03 Line Total: *
*auto-filled
Newspaper Ad03 Scheduling: *
Use the NOTES box below if you need more space.
Web Banners
Size of Web Banner01 *
Monthly Rate of Web Banner01: *
Number of Insertions of Web Banner01: *
Web Banner01 Line Total: *
*auto-filled
Web Banner01 Scheduling: *
Start and End dates required.
Size of Web Banner02 *
Monthly Rate of Web Banner02: *
Number of Insertions of Web Banner02: *
Web Banner02 Line Total: *
*auto-filled
Web Banner02 Scheduling: *
Start and End dates required.
Digital Campaigns & Organic Posts
Digital Campaign01 selection: *
Custom campaigns should be detailed in the NOTES field below.
Weekly Rate of Digital Campaign01: *
Number of Weeks of Digital Campaign01: *
Digital Campaign01 Line Total: *
*auto-filled
Digital Campaign01 Scheduling: *
Include start and end dates for digital campaigns. Include post dates for Organic posts. Use the NOTES box below if you need more space.
Digital Campaign01 audience language: *
Digital Campaign01 total impressions: *
Target impression count for the entire length of the campaign.
Digital Campaign02 selection: *
Custom campaigns should be detailed in the NOTES field below.
Weekly Rate of Digital Campaign02: *
Number of Weeks of Digital Campaign02: *
Digital Campaign02 Line Total: *
*auto-filled
Digital Campaign02 Scheduling: *
Include start and end dates for digital campaigns. Include post dates for Organic posts. Use the NOTES box below if you need more space.
Digital Campaign02audience language: *
Digital Campaign02 total impressions: *
Target impression count for the entire length of the campaign.
Production Charges
Do you need to add any production charges? (Video production, printing costs, etc)

Yes No
What kind of Production? *
E.G. - Video production fee or translation for an employee manual, etc.
Production Charge Rate: *
Production Charge Quantity: *
Production Charge Line Total: *
*auto-filled
Sales Tax
Any additional information about production?
List any other information needed for the billing of this production charge. Use NOTES below if you need more space.
Notes

Enter specific information on custom campaigns or products here. You can also use this area to add more scheduling information if needed.
Is this client tax-exempt? *

No Yes
We will require a copy of the client's tax-exemption certificate to be on file before this Media Agreement can be approved. Please send it to Dawn ASAP.
Billing totals
Contract-Subtotal
If this does not look accurate, check the "Line Total" entries above. *auto-filled
Contract Total (NET)
*auto-filled - Includes SALES TAX if any production charges are entered.
reply-to mail (hidden and locked)
Hidden reply-to e-mail field
Should be Empty:

Media Agreement

Client Information:

Product Information:

Newspaper Ads

Web Banners

Digital Campaigns & Organic Posts

Production Charges

Notes

We will require a copy of the client's tax-exemption certificate to be on file before this Media Agreement can be approved. Please send it to Dawn ASAP.

Billing totals