Email Newsletter Media Buying Authorization

Company Name:
Contact Name:
Email Address:
Phone Number:

Newsletter Name:
Send Date(s):
Audience/Segment:

Ad Format (e.g. Banner, Native):
Ad Size/Position:
Number of Insertions:
Creative Due Date:

Total Cost:
Payment Terms:
Special Instructions:

By signing below, the advertiser authorizes the above email newsletter media buy and agrees to the terms outlined herein.