DigiClips, Inc. Service Request Form

819 Beauprez Avenue Client # (internal use): __________________

Lafayette, Colorado 80026 Start Date: __________________

Email: pbshapiro@digiclipsinc.com Your Purchase Order #: __________________

Phone: (303) 926-0334

PRINT THIS FORM OUT AND FAX TO: (303) 664-1951

SEND RESULTS TO:

Name: ____________________________________________________________________________

Organization ________________________________________________________________________

Address: _________________________________________________________________

City: ________________________________State _______________Zip ___________

E-Mail: _______________________________________________

Phone: _____________________________ Fax: ______________________________

SEND INVOICE TO:

Address: ____________________________________________________________________

____________________________________________________________________

Bill Our Credit Card Number: ____________________________________________________

Expiration Date: ______________________________________________________________

Track Media: __ Print __ Broadcast __ Internet/Web

Include Options: __ Digital Clippings (press clipping format) __ Media Analysis

Check geographic area __ Colorado __ Midwest Region __ National __ International

Other States ____ ____ ____ ____ ____ ____ ____

Check items you want to OMIT (this can be changed at anytime):

__ Births, patient admissions __Wire Services __Weddings/engagements

__Letters to the editor __Calendar Items __Advertisements

__ Sports Listings/box scores __Stock Listings __Editorials __ Obits

Key words/subjects:

________________________________________________________________________________________________

__________________________________________________________________________________

Misc. Instructions: ___________________________________________________________________

__________________________________________________________________________________

Signed: _____________________________________ Date: _________________________________

DigiClips, Inc. is not responsible and cannot be held liable for loss of magazines, newspapers, broadcast or any other published information resulting from human error, equipment failure, Acts of God, bad tapes, transcription error through Closed Captioning or changes in broadcast time due to special events. Material supplied by DigiClips, Inc. may be used for file and reference, internal review, analysis or research only. Any editing, reproduction, rebroadcasting or public display is strictly forbidden. DigiClips, Inc. news segment summaries are derived from off-air recordings, news papers, magazines, periodicals and DigiClips, Inc. is not responsible for the content. DigiClips, Inc. is acting in your behalf as your agent to record Radio and Television programming and to clip news paper, magazine and other periodicals for you and your organization.