Per 1000 Order Form - Need-A-Lead

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

Zip Code

Email Address *

CC:

How do you want to recieve your leads? *

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

Counties

List desired counties in preferred mailing order from top to bottom. Press enter after typing each county.

Counts per Zip Code

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 *

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 *

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