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Date*

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (Best Contact Number)*

Email (That you will use for Correspondence)*

Enter Email Confirm Email

Website*

Company Name*

Company Phone*

This is the phone number that you will use for your forwarding number on your campaign.

Company Info - Who?*

This will be the information needed for who you are.

Company Info - Where?*

This is where you are located. Your business location.

Campaign Information*

How many texts will you send out per month?*

Opt In or CSV?*

How will you be obtaining your contacts? Will you have a landing page for opt ins or will you supply a csv list to be imported?

DISCLAIMER*

Please check that you have read the disclaimer.

Via Connections is a third party virtual management service. Via Connections will not be liable for loss, damage or delay of Client’s project due to circumstances beyond our control. Such circumstances may include (but are not limited to) acts of God, public unrest, power outages, and inability to contact Client. In the event of such loss, damage or delay, Via Connections will make every effort to notify Client/s immediately.

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