Program Enrollment Order Form

Marketing Materials Information

Location or Area (i.e. Central Florida)

Website

Phone Number

Street

City

State

Zip Code

If you have additional Contacts, please email LocaliQCCChanges@clientcommand.com with the same fields listed above

Campaign Information

Expected Start Date

Please fill the date in MM/DD/YYYY format

Select Number of Sales Records

Please enter your Custom Number for Sales Data Records

Are you also purchasing Email Deployment by Client Command?

YesNo

Targeted Market

Target Zip Code

What radius was presented in the Sales Process?

Comments regarding Target Zip Code

LocaliQ Info

	First & Last Name	Email	Phone Number
Account Executive
Client Success Manager

LocaliQ Internal Information

Adpoint ID

If you receive an error message from a field that requires an email address, please make sure to remove any spaces before or after the email address.