Mike Church Show Advertising Sales Form -

Company Name *

Date *

Business/Organization Name *

Contact Person *

First

Last

Email *

Phone Number *

Billing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please tick the desired item

Total Amount

$0.00

Stripe Credit Card *

Card

Name on Card

A 50% deposit for the first month's advertising is required

Desired advertising copy

Confirmation *

I acknowledge that I have read and agree to abide by the the Terms and Conditions
I acknowledge that upon submitting this form, my orders are final and can no longer be canceled