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Part 1: Contact Information

Agency Name:
Contact's First Name:
Contact's Last Name:
Address:
City:
State: Zip:
Phone: Fax:
E-Mail:
Website:

Part 2: Business Information

Business is a: Corporation Partnership
Year Founded:
Provide a brief history of agency:
Describe your agency's area of expertise:
Area served by main office: International National Local
In which states or provinces are your primary accounts located:
Do you have a branch office(s)? Yes No
If 'Yes', where?
What general areas do your branch offices serve?
Number of accounts served by each office?

Part 3: Employee Information

List principals and executives, including owner, active in work of agency.
Name Position Years with
Present Firm		 Years in
Advertising
Number of people employed by your agency?
Employed at main office?
Employed at branch office?
Is anyone in your organization retained by, or employed by, a representative of the media:
Yes No
If yes, please explain:

Part 4: MCAN Representation

Who will represent your office at MCAN meetings?
Title of the representative?
Does this person plan to attend all meetings? Yes No
If 'No', name of substitute representative at the meeting:
Title of the representative?

Part 5: Billing Information

Agency annual billings: (6.67 x gross profit = annual billings)
Number of accounts you currently have on roster:
Total B-to-B Retail Service Consumer
Are any of your commissions directly or indirectly rebated to the client? Directly Indirectly
Is basis of remuneration same for all clients: Yes No
If not, please explain method of billing:
Do any of your clients have financial interest in your organization: Yes No
If yes, please explain:

Part 6: Additional Information

List any other information you feel would be of interest to your members and network:
List advertising or trade associations to which you or your agency belongs:
List major clients and length of time your agency has served these clients:
List media association which have recognized your firm:

Part 7: Submission Information

Your Name:
Agency Title: