LEAD CONNECTION-DIRECT MAIL BY PIECE ORDER FORM
TERMS AND CONDITIONS:

LEADS ARE $30.00 EACH
MINIMUM ORDER IS 20
DEMOGRAPHICS USED WILL BE AGES 50-80 AND INCOME 10K TO 50K
LEADS WILL BE EMAILED TO YOU AS A PDF ATTACHMENT
ORIGINALS WILL BE MAILED WEEKLY ON TUESDAY
ADDITIONAL LEADS GENERATED OVER THE AMOUNT PURCHASED WILL BE OFFERED FOR 1/2 PRICE. THESE ARE NOT MANDATORY FOR PURCHASE.

CURRENTLY THE BELOW STATES ARE NOT AVAILABLE. THIS IS SUBJECT TO CHANGE AT ANY TIME AND AT THE DISCRETION OF THE VENDOR. YOU WILL BE NOTIFIED IF A LEAD ORDER IS SUBMITTED AND THE STATE IS NO LONGER AVAILABLE.

AL
AZ
FL (except for the Panhandle area)
GA
KY
OH
SC
TN
TX


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AGENT NAME: *
PHONE NUMBER: *
Date: *
MM
/
DD
/
YYYY
EMAIL ADDRESS TO SEND LEADS: *
NUMBER OF LEADS (MINIMUM ORDER 20): *
PREFERRED DEMOGRAPHICS - ZIP CODES, COUNTY OR STATE(S) *
LEAD PIECE (SAMPLE AVAILABLE ON OUR WEBSITE) *
Required
CREDIT CARD TYPE: *
NAME ON CREDIT CARD: *
CREDIT CARD NUMBER: *
CREDIT CARD EXPIRATION DATE: *
3-DIGIT SECURITY NUMBER: *
ADDRESS ON CREDIT CARD (CITY, STATE AND ZIP: *
SHIPPING INFORMATION *
Required
SHIPPING INFORMATION (IF DIFFERENT THAN BILLING)
TERMS AND CONDITIONS
*Terms and Conditions – by submitting this form you understand that this amount will be charged to your credit card and you agree to the above terms.
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