Client Information Form

Client Information Form
Advertiser Common Name:
Advertiser Legal Name:*
Who is your Account Executive?
Advertiser Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Advertiser Phone Number:*
Please enter a valid phone number.
Contact Name:

First NameLast Name
Contact Phone Number:*
Please enter a valid phone number.
Contact Email*
example@example.com
Preferred Billing Method:*

Mail - USPSEmail/electronic Invoicing
Billing Contact Name:

First NameLast Name
Billing Phone Number:
Please enter a valid phone number.
Billing Email:
example@example.com
Your form will be submitted to payments@yourtotalmedia.com.

All mailed payments can be directed to:

Total Media Group, Inc.

708 E Main St

PO BOX 667

Jackson, OH 45640

Download a W9 and get information about our new PayNow portal for electronic invoice and online payments at yourtotalmedia.com/tmgpayments.

Thank You for updating us with your information!
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