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Choose Ad Type
*
Business –
$250.00
Individual –
$50.00
“Business” must be a corporation with more than one member
Event Date/Name
Business Name
*
(All corporations, LLCs, PSCs, and sole-proprietorships; individuals may enter ‘n/a’)
Purchaser Name
*
First
Middle
Last
Business Address
*
Address Line 1
City
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Rhode Island
South Carolina
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Tennessee
Texas
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Vermont
Virginia
Washington
West Virginia
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Wyoming
State
Zip Code
Email
*
Phone
Certification
CERTIFICATION
*
By checking this box, I agree to the following:
I hereby certify and state that all of the information disclosed by me and set forth above on this form is true and accurate to the best of my knowledge and belief.
I certify that this purchase is being made from the funds of the business or individual placing the ad.
I certify that, to the best of my knowledge, my total advertising purchases during this election cycle will not exceed the applicable statutory limit of $250 for a business or $50 for an individual.
Payment Method
Payment Card
*
Total Amount
$0.00
Phone Total Method
SUBMIT