New Client Information Company or Organization Name*Contact Person at Business or Organization* First Last Is this Business or Organization Represented by an Agency?*YesNoAgency Name*(If applicable)Contact Person at Agency First Last Business or Organization Phone*FaxEmail* Street Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Is This Address Also Your Billing Address?*YesNoBilling Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Category or Industry of Business*Number of Years in Business*Company Type*Sole ProprietorshipPartnershipCorporationNon-Profit (501c3)Invoices to be Received*Electronic Billing using eInvoicingPaper OnlyEmail Address for Electronic Billing* Name of Mid-West Family Sales Representative*If you do not know the name of your representative, type "Unknown."NEW CLIENT TERMS: AN EXISTING BUSINESS that has never been on the air with our stations, or never aired a :30 second or :60 second commercial schedule with our stations, or has not been on the air for the past three years, will be required to make full payment in advance of running the schedule. A NEW BUSINESS must have at least 6 months credit history with the station to be considered for normal credit terms. Credit history is established with payment in advance of scheduled advertising month by month for 6 consecutive months. Credit terms of a new business will be re-evaluated at the end of 6 months and standard credit terms may be granted at that time. CASH IN ADVANCE. A money order, credit card (VISA, Discover, American Express or Master Card) or certified bank check is preferred. Local checks must be deposited at least 7 business days prior to a schedule airing. Out of town checks must be deposited at least IO business days prior to a schedule airing. Full payment is required prior to schedule airing. If full payment has not been received, schedule and/or sponsorship will be pulled. BARS, RESTAURANTS.SEASONAL AND TEMPORARY BUSINESSES: Terms for bars, restaurants, seasonal and temporary businesses are: FULL PAYMENT DUE IN ADVANCE OF SCHEDULE! Standard Credit Terms will not be extended. Non-Sufficient Funds Fee - A $25 NSF fee will be assessed for all checks returned to us from the bank. CREDIT TERMS (NET 30 DAYS): All accounts that have met the above criteria will be billed upon the completion of an advertising schedule with payment expected in full within 30 days. PAST DUE ACCOUNTS: Any account that does not pay within 30 days is considered past due! Full payment of that balance is required immediately. If a client cannot pay the full balance, a SIGNED PAYMENT PLAN must be on file with a partial payment. Any account without a signed payment plan and with a past due balance of greater than 90 days will be turned over for collection. QUESTIONS OR PROBLEMS: Should you have any questions or note any discrepancies in your billing, please call your Station Representative! In the event of cancellation, a written notice is required 4 weeks prior to the cancellation date and at the end of the broadcast month for billing purposes. Oral notice shall not apply. ADVERTISING DISCLAIMER: This station does not discriminate in the sale of advertising time, and will accept no advertising that is placed with an intent to discriminate on the basis of race or ethnicity. Advertiser hereby certifies that it is not buying broadcasting air time under this advertising sales contract for a discriminatory purpose, including but not limited to decisions not to place advertising on particular stations on the basis of race, national origin, or ancestry. IT IS AGREED THAT THESE PAYMENT TERMS SHALL APPLY TO ALL ADVERTISING ORDERED BY THE ADVERTISER:Owner/Officer Signature of Business or Organization*Consent*I agree that my signature indicates commitment of responsibility, personally, for payment of any and all charges made at WSJM INC. / Mid-West Family - South Bend I agreeCAPTCHABefore submitting, please click the box and follow any verification prompts.