Note : All Fields marked with * are compulsory      TV AND RADIO MEDIA FORM    Name* first     last    Address    City    State    Zip Code    Email Address    Telephone No.    Fax No.    Date Established 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 DD      Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec MMM       1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 YYYY    Federal I.D. Number    Owner Mr. Ms. Mrs. First       last    Program Manager Mr. Ms. Mrs. First       last    Advertising Manager Mr. Ms. Mrs. First       last    Tape Size    Type of Tape    Address materials shuold be send to    Coverage area    Person to Contact Mr. Ms. Mrs. First       last    Air Time. Dates      Start am pm 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 DD      Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec MMM       1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 YYYY    Cancellation Date.    Name of Program Channel          Source of Audience    Rating    Language of Program    Area of Broadcast    Name of Station Program          Do rates reflect 15% agency commission ?        Yes No    If yes, please indicate if rate quoted are net or gross    Frequently Levels Open rate 1x    Rate (:60 units)                Write a brief comment about the    station/program