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SERVICE REQUEST FORM

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FIRST NAME LAST NAME

EMAIL ADDRESS PHONE NUMBER

ORGANIZATION

ADDRESS

CITY STATE ZIP CODE

COUNTRY

ORDER NEEDED   □ All    □ MEDIA REPORT    □ TELEVISION CLIP    □ RADIO CLIP   

KEYWORDS PHRASES

TELEVISION STATIONS

CABLE TV STATIONS

ARCHIVED DATES

FORMAT OF TELEVISION DOWNLOADS  □ All    □ mpeg    □ wmv    □ mp4    □ mov   

FORMAT PC OR MAC  □ All    □ PC    □ MAC   

TELEVISION RESOLUTION  □ All   □ Hi Resolution   □ Standard Resolution  

RADIO STATIONS

FORMAT OF RADIO DOWNLOADS  □ All    □ mp2    □ wmv   

NEWS PAPERS MAGAZINES

WEB STREAMING LINK CAPTURED AND EDITED

MEDIA LINK VERBATIUM TRANSCRIPT

DATES:

TIMES:

NATIONAL INTERNATONAL MARKETS

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LEGAL

DigiClips ® is a U.S. registered service mark of the Robert and Paula Shapiro Living Trust, and used by Digiclips, Inc. under a license agreement with the Trust.