Per 1000 Order Form Per 1000 Order Promo Code Please check the correct box below. * 1st Time Order Returning Customer (ordered within the last 6 months) Returning Customer (last order was more than 6 months ago) First Name * Last Name * Company Name Agent Code Phone * Fax Mailing Address * City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Code Email Address * CC: How do you want to recieve your leads? * Mail Hard Copies Only Email Scanned Copies Only Both Hard Copies and Scanned Lead Criteria: Age Birth Months Income P.O. Boxes * Yes No Housing Exclusion - Add $10 Include Renters Only Include Homeowners Only Gender Exclusion - Add $10 Include Male Only Include Female Only Racial Exclusions - Add $35 If you desire to target a specific ethnic group please enter it in the above field. Lead Piece * Exp: NAL-_____________ Total # of Mailers * (Exp: 2000) Lead Piece Mailing State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Counties List desired counties in preferred mailing order from top to bottom. Press enter after typing each county. Counts per Zip Code (Example: 83702 count 1000) List zip codes and counts for each zip code in preferred mailing order from top to bottom. Press enter after each entry. Cost Total Cost w/Exclusions Payment Type * Credit Card E-Check E-Check Account Type Checking Savings Business Checking Account Holder First Name Last Name Routing # Account # Credit Card Type Visa Mastercard American Express Discover Cardholder First Name Last Name Credit Card # Expiration Date 3 Digit Security Code Billing Street Address * City * State * AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Code * Keep my payment method on file for future orders Yes No Order Comments Terms and Conditions * I agree to the Terms & Conditions and understand that Need-A-Lead does not guarantee lead returns. A lead is an opportunity to sell a product and is not a guaranteed sale. I understand once an order has been mailed Need-A-Lead will not refund any money. Payment Policy * My signature gives Need-A-Lead permission to process my order and charge my credit card or e-check. I acknowledge that if paying with an e-check the origination of ACH to my account must comply with the provisioning of United States law. By checking this box and typing my name below, I am electronically signing this application. * I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature. First Name * This is my official digital signature Last Name * Date * reCAPTCHA If you are human, leave this field blank.