< Back to Co-op Info Fields Co-op Advertising Request Form
Mail To:
2240 Taylor Way
Tacoma, WA 98421
(206) 627-4098
(800) 627-4098
Fax (206) 383-2181

Dealer: ________________________________________

Date: ______________

Distributor Requesting Credit:

______________________________________________

______________________________________________

______________________________________________

Media: Required Checklist:
Newspaper

__ Full page Tear Sheet(s)

__ Invoice

Catalog, Mailer, Circulars

__ Complete Copy of Printed Material

__ Proof of Cost for Printing & Distribution (Paid Invoices)

__ Proof of Circulation

Other (Prior Approval by Fields)

Radio __

Television __

__ Paid Invoices and Evidence of Air Time
 

Total Amount: ______________

50%: ______________

 

For Fields Use

Amount of Payment $: _____________________________

Approved By: ___________________________________

Date:__________________________________________

Please print and include this form with all calims.