Update/Cancel Media Agreement
Job Order # that you want to cancel or update:
Who are you?
*
Jairo
Miguel
Danielle
Suzett
Dawn
Purpose of this Media Agreement?
*
Please Select
CANCELLATION
UPDATE
*For the last two options, please have the existing Job Order Number ready to enter below.
Date
*
.
Month
.
Day
Year
Date
Primary salesperson?
*
Please Select
Jairo
Miguel
Berenice
Danielle
Suzett
House
Is there a second salesperson?
Please Select
Jairo
Miguel
Berenice
Danielle
Suzett
House
Client Information:
Client Name
*
Client Contact
*
Agency Name
Billing Contact
Address
*
City
*
State
*
Zip
*
Phone
*
Fax
Mobile
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 need to cancel or update:
A Newspaper Ad
A second Newspaper Ad
A third Newspaper Ad
A Web Banner
A second Web Banner
A Digital Campaign
A second Digital Campaign
Newspaper Ads
Newspaper Placement Requirements
Does client want digital tear sheets?
YES
Size of your Newspaper Ad 01
*
Please Select
Double-Truck (21" x 10.7")
Full-Page (10" x 10.7")
Three-Quarter V (7.5" x 10.7")
Three-Quarter H (10" x 8")
Half V (5" x 10.7")
Half H (10" x 5.3")
Quarter V (5" x 5.3")
Quarter H (10" x 2.6")
Eighth V (2.5" x 5.3")
Eight H (5" x 2.6")
Credit Card (2.5" x 2.6")
Half-Credit Card (2..5" x 1.25")
Line-Class
Custom (Detail in Notes)
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
*
Please Select
Double-Truck (21" x 10.7")
Full-Page (10" x 10.7")
Three-Quarter V (7.5" x 10.7")
Three-Quarter H (10" x 8")
Half V (5" x 10.7")
Half H (10" x 5.3")
Quarter V (5" x 5.3")
Quarter H (10" x 2.6")
Eighth V (2.5" x 5.3")
Eight H (5" x 2.6")
Credit Card (2.5" x 2.6")
Half-Credit Card (2..5" x 1.25")
Line-Class
Custom (Detail in Notes)
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
*
Please Select
Double-Truck (21" x 10.7")
Full-Page (10" x 10.7")
Three-Quarter V (7.5" x 10.7")
Three-Quarter H (10" x 8")
Half V (5" x 10.7")
Half H (10" x 5.3")
Quarter V (5" x 5.3")
Quarter H (10" x 2.6")
Eighth V (2.5" x 5.3")
Eight H (5" x 2.6")
Credit Card (2.5" x 2.6")
Half-Credit Card (2..5" x 1.25")
Line-Class
Custom (Detail in Notes)
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
*
Please Select
Leaderboard (768x90)
Banner (345x144)
Badge (110x65)
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
*
Please Select
Leaderboard (768x90)
Banner (345x144)
Badge (110x65)
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
Digital Campaign01 selection:
*
Please Select
GOLD - Spanish
SILVER - Spanish
GOLD - English
SILVER - English
CUSTOM - Detail in NOTES
Custom campaigns should be detailed in the NOTES field below.
How will you bill Digital Campaign01?
*
Charge per week
Flat amount for entire campaign
Weekly Rate of Digital Campaign01:
*
Number of Weeks of Digital Campaign01:
*
Total campaign cost for Digital Campaign01:
*
This is not a weekly rate but rather the full cost of the digital campaign.
Digital Campaign01 Line Total:
*
*auto-filled
Digital Campaign01 Scheduling:
*
Include start and end dates. Use the NOTES box below if you need more space.
Digital Campaign01 audience language:
*
Please Select
English
Spanish
Digital Campaign01 total impressions:
*
Target impression count for the entire length of the campaign.
Digital Campaign02 selection:
*
Please Select
GOLD - Spanish
SILVER - Spanish
GOLD - English
SILVER - English
CUSTOM - Detail in NOTES
Custom campaigns should be detailed in the NOTES field below.
How will you bill Digital Campaign02?
*
Charge per week
Flat amount for entire campaign
Weekly Rate of Digital Campaign02:
*
Number of Weeks of Digital Campaign02:
*
Total campaign cost for Digital Campaign02:
*
This is not a weekly rate but rather the full cost of the digital campaign.
Digital Campaign02 Line Total:
*
*auto-filled
Digital Campaign02 Scheduling:
*
Include start and end dates. Use the NOTES box below if you need more space.
Digital Campaign02audience language:
*
Please Select
English
Spanish
Digital Campaign02 total impressions:
*
Target impression count for the entire length of the campaign.
Production Charges
Do you need to add any production charges?
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
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 other information for this cancellation or update here. You can also enter the full schedule here if needed.
Billing totals
Contract-Subtotal
If this does not look accurate, check the "Line Total" entries above. *auto-filled
Sales Tax
Dollar amounts only - no percentages!
Contract Total (NET)
*auto-filled
Submit
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