Friends & Neighbors Request FormPosted on August 27, 2015 IF THE FORM FAILS TO LOAD PLEASE REFRESH THE PAGE. Step 1 of 3 33% Name* First Last Email* Daytime Phone*Evening Phone*Is this a 501 (c) (3) Nonprofit Organization Event*YesNo501 (c) (3) Number* What Type of Event is This? (CHECK ALL THAT APPLY)* On Site Event Awareness Campaign Name of the organization that’s organizing or hosting the event/fundraiser/campaign*Name of the Event/Campaign*Date of the Event* Event Starting Time* : HH MM AM PM Event Ending Time* : HH MM AM PM Event Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Additional Campaign Details*Describe your awareness campaignSpecific Instructions or Directions Name of Person In Charge of The Event/Organization* First Last Does this Event Have a Media, Public Relations or Spokesperson?YesNoMedia / Public Relations / Spokesperson Contact (if any) First Last Media / Public Relations / Spokesperson Contact Phone NumberEmail Specific Objective of This Event or Campaign*Who Benefits? What is the goal of the event, campaign and/or message?Do we need to know anything more about your event/campaign?Add any additional details or specifics about your event or organization that will help us tell your story.Check All That Apply* I want to be on the 95.5 WFMS Website I want to be mentioned in on-air announcements I want an on-site visit from 95.5 WFMS Friends & Neighbors I want to be on the 95.5 WFMS Friends & Neighbors Radio Program *I (vendor) herby agree that it will not hold liable Susquehanna Radio Corp., a wholly owned subsidiary of Cumulus Media Partners LLC, radio station(s) WFMS, and their parent company, subsidiaries, affiliates, members, directors, officers, employees and agents (the “Cumulus Parties”) for any loss, injury or damage to Vendor’s property or the Vendor’s employees, representatives or agents, due to fire, theft, accidents, or any cause whatsoever that may arise or occur in connection with their participation in the submitted event. Vendor herby covenants and agrees to indemnify and hold harmless the Cumulus Parties, from and against any and all claims, liabilities, losses, and costs (Including reasonable attorney’s fees) arising from or in connection with Vendor’s participation in the Event (meaning, without limitation, Vendor’s acts and omissions or the acts or omissions of Vendor’s employees, affiliate or representatives) and any products and services provided by the Vendor in connections with the Event. I Agree
