Morris Network New Advertiser Form And/Or Advertising Agency Recognition

Name
MM slash DD slash YYYY
Address
Mailing Address

Description of Business

MM slash DD slash YYYY

Principal Owners, Partners, Officers

Name
Address

References

Please list three (3) media billing references (Radio, Television, Newspaper, Billboard)
Name
Name
Name
Address
Address
Address

Banking and Other Financial Information

Address

Client Listing (Agencies and Buying Services Only)

Please list three (3) principle advertising clients:
Name
Name
Name
Address
Address
Address

Customer Signature

The undersigned hereby represents that the information contained on this form is accurate and acknowledges that it is furnished for the purpose of securing terms and recognition from WWAY-TV, LLC, Leland, NC. The undersigned authorizes WWAY-TV, LLC to make inquiries and obtain information necessary and reasonable concerning any statements or requests made, and further authorizes the release of information by any party contacted in relation to such request. The undersigned guarantees payment for the above-described firm of all obligations, which result from extending terms to such firm by WWAY-TV, LLC.
Name
MM slash DD slash YYYY