Pipeline Media

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Account Code:
(If you do not have an Account with Pipeline, please call 1-866-244-1445 or click here to have one set up)
Company Name:
Contact Person:
Email Address:
Telephone Number:
Date to Transmit:
Month
Day
Year

Time to Transmit:
Time Zone:
Number of Merge Points to be placed on the Document/message:

*(Make sure you clearly indicate the location of the merge points)*
Do You Require a Test Prior to the Broadcast Delivery?
	Yes No
If Test is Required:
Fax Number
Email Address

List File 1
List File 2
List File 3
List File 4
List File 5
*(Column headers must match merge points indicated on your document/message)*
Document/Message File 1
Document/Message File 2
Document/Message File 3
Document/Message File 4
Document/Message File 5
“From” text to appear at the top of each fax:
Remove duplicate numbers from list:	Yes No
If an Email Broadcast, please include:
Sender Name
Reply Email Address
Subject Field
Special Instructions:
It may take up to 1 minute to upload your files. Please do not hit SEND more than once. A confirmation will be displayed once your files have been successfully uploaded.