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 AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Code Email Address * CC: How do you want to recieve your leads? * Mail Hard Copies OnlyEmail Scanned Copies OnlyBoth 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming 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 * AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY 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.
