Name:

Title: 

Organization Legal Name:

Publication: Where will the results of the Poll or Responses be published?

Will Results Appear on Organization's Website:  Yes    No    Not Sure

Will Results Be Aired on Television:  Yes    No    Not Sure      If so, what station: 

Company's Website: 

Phone Number:  Fax Number: 

Email: 

My organization is bidding on the response (i.e., raw data) of the question: 

All bids start at $1,100.00 with increments of $100.00. Amount of Bid: