| * 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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Is what you want to advertise a product or service? |
Product
Service |
What is its name? |
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Give us a short description of your product/service: |
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What are the benefits of your product/service (select all that apply)? |
Time Saver
Money Saver
Life Saver
Effort Saver (makes life just a little or a lot easier)
Other (describe below)
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| How do you want to pay for performance? |
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 |
| What Media do you want to use? |
(select all that apply.) |
| 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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| Do you have a call center? |
Yes
No |
| If you do have a call center what hours do they answer calls? |
24/7
Monday-Sunday specific hours
Monday-Friday 24 hours
Monday-Friday specific hours
Other [explain below]
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| You understand (and accept) that HPM requires an refundable account opening security deposit equal to 200 leads? |
Yes
No
Other:
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| Please attach a sample of your daily report |
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| 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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