ACCEPTED AND AGREED TO:
| ______________________________ | ______________________________ |
| Client’s Signature | Mailing Address |
| ______________________________ | ______________________________ |
| Printed Name | City, State, ZIP |
| ______________________________ | ______________________________ |
| Date | Phone Number |
| ______________________________ | ______________________________ |
| Co-Client’s Signature (if applicable) | E-mail Address |
| _____________________________ | _____________________________ |
| Printed Name | FAIR COVERAGE |
| ______________________________ | ______________________________ | Date | Date |
Fair Coverage Dot Com
P.O. Box 2922
Culver City, CA 90231-2922