Name:

Organization:

Address:

City:

State:
AL - Alabama AK - Alaska AZ - Arizona AR - Arkansas CA - California CO - Colorado CT - Connecticut DE - Delaware DC - District of Columbia FL - Florida GA - Georgia HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MD - Maryland MA - Massachusetts MI - Michigan MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV - Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VT - Vermont VA - Virginia WA - Washington WV - West Virginia WI - Wisconsin WY - Wyoming

Zip:

Telephone:

No dashes or spaces: 5555555555

Fax:

No dashes or spaces: 555555555

Email:

Is there a preferable time for us to contact you?:

How did you find out about Names in the News?:

What does your organization do?:

Are you a regional mailer?
Yes No

If yes, in what area?:

How many names would you like to mail?:

When would you like to mail them?:

Does your organization have a mailing list available for exchange?
Yes No

If yes: How many names are on it?:

What types of names are included (e.g. donors, petition signers, event attendees):

If the list is not just donors or members, what percentage of the file has contributed at least $5?:

In what format can you provide the names? (eg: CD, FTP, email):

Additional questions about our services?: