Business Name:
Address:
City: State: Zip:
Business Phone:
Business Fax:
Email Address (required):
Websites Address (if you have one):
Your Name: Your Title:
Your Phone Number:
Purchase Order Number (if required):
How did you hear about us?
Please tell us who referred you:
AD COPY: Please type in the box below.
LOGO'S AND PICTURES: Email us these items in .jpg format only.
COMMENTS: If you have any questions or comments make them here. We will reply as soon as
possible.
The Value Minute: Please note, a Representative from Cable One, KPAX TV and
ShopTheFourStates.Com will each contact you separately for their portion of the ad copy for the
Value Minue Advertising Package.
