2. Today’s Date:*
   NO EARLER THAN 8 WEEKS AND NO LATER THAN 4 WEEKS PRIOR TO EVENT
4. Requesting Organization:*
6. Contact Phone Number:*
8. Contact Email Address:*
10. Title of Event/Program:*
12. Date of Event/Program:*
14. Location of Event/Program:*
16. Starting Time of Event/Program: *
    Please indicate AM or PM
18. Ending Time of Event/Program: *
    Please indicate AM or PM
20. Brief Description of Event/Program:*
22. What 3 weeks would you like to run your message?*
24. Start Date:*
26. End Date:*
28. Additional Comments:
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30. 1. Receive an email copy of this form.
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