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New Media Outlet Registration

Thanks for your interest in becoming an HPM Media Partner. By completing this form, you'll automatically be registered in our system, enabling you to access our Client Offers and place orders for any ad(s) you want!
First Name
Last Name
Company
How did you find out about HPM's PI program?

Do you have media outlets/stations you represent ? Yes No

Title
Address
If you are signing up as a TV or other media outlet that will need spots shipped to you please enter a physical address. We cannot ship to PO Boxes
City
State
Zip/Postal Code
Phone nnn-nnn-nnnn
Cell
Fax
Email
Please only enter one email address as this will be used as your logon to our site
Website
Is this a national or local/regional outlet National Local/Regional
Kind of Media: Radio TV Mobile Audio Mobile Video Mobile Web Print Online
Mobile Directory Assistance other (please specify)
Is your Traffic Manager contact information the same as above? Yes No
Is your Accounts Receivable Manager contact information the same as above? Yes No
Are you the person who will receiving weekly/monthly reporting Yes No
I have read, understood and agree to be bound by the terms of HPM's Terms of Service. (check box to agree)
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