If you plan to send multiple mailings, you must submit a separate Request Form and Messaging for each mailing. Please email firstname.lastname@example.org or call 301-860-4310 for questions about this form.
Explain the purpose of the email:
Target Audience (Select all that apply):
Define other target audience if you select others above:
Provide specific criteria for your target location (e.g. List each state if you select States above)
Send Date and Time (date MUST be at least 14 days after request date):
"Reply To" E-mail address:
(Please provide specific "Call to Action" on the body of the email)