| * First Name: |
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| * Last Name: |
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| * Company Name: |
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| * Address: |
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| * City : |
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| * State: |
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| * Zip: |
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| * Phone: |
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| Fax: |
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| * E-mail: |
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| Website: |
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| What Media do you want to use? |
(use control key to select more than one.) |
| Is your offer a lead generator, hard sell offer or soft sell? |
Lead Generator
Hard Sell
Soft Sell |
| Do you want to pay on a cost per call, cost per lead or cost per sale? |
Per Call
Per Lead
Per Sale
None of the above |
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| What is your definition of a lead? |
If other, please specify
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| How soon do you want to start? |
As soon as possible
2-3 months
3-6 months
I'm just starting up and am not sure |
| Do you need HPM to produce your ads? |
Yes
No |
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| Do you want HPM to supply you with toll-free numbers? |
Yes
No
Unsure |
| HPM will supply you with all toll-free numbers and furnish all reporting. |
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| Please attach a sample of your daily report |
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| You accept that to open an account with HPM you agree to make a fully refundable deposit equal to 300 leads. |
Yes
No
Unsure |
| Please attach an example of your ad(s) for us to review
and evaluate; we will not share this creative with anyone without your authorization. |
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| What else should we know about your program that will help
us better understand your current situation and what you want to have happen? |
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| Enter Code |
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