BILLING FORM Please Complete The Form Below Billing Form Business / Organization Name Business / Organization Billing Contact Business / Organization Billing Contact First Name First Name Last Name Last Name Business/Organization Digital Ad Content Contact (if different from the billing contact): Business/Organization Digital Ad Content Contact (if different from the billing contact): First Name First Name Last Name Last Name Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone Email Preferred method for invoicing? Mailed Copy Email Preferred payment method? Check Credit Card/pay online directly from the invoice ACH Does this account require a purchase order number? Yes No Preferred structure? Monthly Quarterly Annually Does it have an expiration date? Yes No What is the billing amount? Does this need to be set up on reoccurring? Yes No Who is your Digital Pulse Media Sales Representative? Additional Notes: Submit If you are human, leave this field blank.
