Co-op Direct Mail Program List Rental Request Form

Please complete form and send via fax (608/ 264-6150) to the appropriate person below.

Form must be complete for your request to be considered.

List Type

£ DIRECT MAIL LIST – Attn: Wisconsin Call Center

Contact Information

Name: ____________________________________________________________________

Organization: ______________________________________________________________

Address: __________________________________________________________________

City: __________________________________ State: WI Zip: _________________

Phone: _________________________________ Fax: _____________________________

E-Mail: ___________________________________________________________________

Tax Exempt? £ Yes £ No If yes, please include a completed Wisconsin Sales and Use
Tax Exemption Certificate with your completed Rental Request Form.

Promotion Information

Description of promotion: _____________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Date List Needed: __________________

Date of Campaign Launch: __________________

Target Audience

A. Quantity: £ No limit OR £ Limit my list to _____________ records

B. Dates: £ Within the past 12 months OR £ From ____________ to ________________

C. Publications: £ No specific publication OR £ The following publication(s):

£ Arts & Craft Fairs Directory £ Fall/Winter Events & Rec Guide £ Snowmobile Map

£ Attractions Guide/Map £ Golf Course Directory £ Spring Sampler

£ Bed & Breakfasts Directory £ Heritage Traveler £ Spring/Summer Events & Rec Guide

£ Biking Guide £ Lodging Directory £ State Park Visitors Guide

£ Campground Directory £ Native Wisconsin £ Travel Guide

£ Fall Sampler £ Rustic Roads

D. Zip Codes (by first 3-digits) or Area

£ All zip codes OR £ Select zip codes/areas by state

Wisconsin: _________________________________________________________________

Illinois: ___________________________________________________________________

Minnesota: ________________________________________________________________

Iowa: ____________________________________________________________________

Michigan:__________________________________________________________________

Indiana:____________________________________________________________________