Applications for membership are accepted without commitment on the part of the Network and are subject to review and recommendation by the Executive Committee and approval by a majority of the membership. All information submitted will be held in strictest confidence. Please note that all fields are required for consideration. Click here for a downloadable PDF application.

 
Name of Agency
Agency Contact
Contact's Title
Address 1
Address 2
Telephone
Fax
City
State/Province
Country
Zip/Postal Code
Email
Website

Branch office locations

When was your agency established? 

Was there a predecessor agency? yes no

If so, give name explanation:

Is your agency a:



Officers and Partners
Name Title Age Time With Agency

How many total employees, including owners? 

What departments or specialized personnel do you have?

What media recognitions and association memberships do you have?


How many active clients does your agency serve? 

List your 4 (four) biggest clients in terms of income to your agency
Client Name City & State Headquartered In

Time Served

Approximate percentage of annual income in following media:
Newspapers % Television %
Radio % Consumer Publications %
Outdoor % Business Publications %
Point of Sale % Collateral %
Direct Mail % Internet Advertising %
Web Design % Other %

Total capitalized billing (net x 6.6) for last complete fiscal year 

Estimated capitalized billing (net x 6.6) for current fiscal year 

Offices held in community organizations or advertising groups
by key agency executives or owners:




I attest that the information above is accurate to the best of my knowledge and belief, and by completing the following fields I am casting my "Digital Signature" 
Name Title Date


  

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