CONTRACT REQUEST FORM

Email:*

Requestor's Name:

Client:

Job #:

PO #:

Date Submitted:

Shoot Date:

Air Date:

# Of Spots:

EMS Estimate #:

Commercial Type:TV: TvRadio: Radio

Internet/New MediaInternet/New Media

Spanish LanguageSpanish Language

Industrial CAT(1)Industrial CAT(1)

Industrial CAT(2)Industrial CAT(2)

Non-air DemoNon-air Demo

Made for CableMade for Cable

PSAPSA

Title:

Comm’l ID:

Advertiser:

Product/Exclusivity:

Length:

Studio:

City/State:

Time:

# Tags:

Pfc: PfcMtn: Mtn

Ctrl: CtrlEstn: Estn

SS#

Performer Name

Agent

Rate

10%

yes

yes

yes

yes

yes

yes

Category

Role

Media Info:

(type of use, flight dates, cable networks, markets, number of Class A uses, etc.)

Special Delivery Instructions and/or Special Provisions:

(to be noted on contract)

Please attach script and/or storyboard

Submit completed form to EMS by fax or click send to email. Via fax 214-637-0635