Remote Broadcast Order Form | Coxswain Media ⚠ This form must be approved by GM and OM/PD before the event is confirmed. * Indicates a required field 01Billing & Sales Billing Type * Billed Through Station Talent Paid by Client Unpaid Sales Rep * 02Client Information Client Name * Client Contact Person * Contact Phone # * 03Event Details Name of Event * Event Date * Event Time * Talent Requested Exact Address & Directions * Description of Event — Client Benefit / Listener Benefit * 04Appearance Type Appearance – Jock* 2 hours on locationw/ Jock & 2 call-ins per hour Appearance – Jock 2 hours on locationw/ Jock & no call-ins Appearance – No Jock 2 hours on locationw/ no Jock & no call-ins 05Station Selection Which station(s)? * Pixy 103 Frank-FM Y101 Koffee-FM Flexible / Any 06Prizes, Needs & Requests List of Client Prizes Other Special Needs Client Requests 07Technical Requirements Wired hi-speed internet available at venue? * Yes No Unknown / TBD Submit & Send → ✓ Submitted Successfully Your request has been sent and emailed to management.
