Pedestrian Campaign Home Page >> Step-by-Step Guide >> Television Fax-back Form

Television Fax-back Form (This sample can be modified for print, radio, etc.)

Pedestrian Safety Campaign

Dear Editor

Driver/Child Crossing, Driver/Young Girl, Pedestrian/Night Visibility and Pedestrian/Signals
are public service announcements from Anytown's Pedestrian Safety Campaign

Please fax this form back to
(Campaign Coordinator) at 555-555-1212

Number of times you will place the Driver/Child Crossing
____________________________________________________________________

Number of times you will place the Driver/Young Girl
____________________________________________________________________

Number of times you will place the Driver/Child Crossing
____________________________________________________________________

Number of times you will place the Driver/Child Crossing
____________________________________________________________________

Total estimated value of all placements $
____________________________________________________________________

Your comments
____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Name                                               Title
____________________________________________________________________

Station
____________________________________________________________________

Address
____________________________________________________________________

City, State                                         Zip
____________________________________________________________________

Phone                                               Fax
____________________________________________________________________

E-mail
____________________________________________________________________

By using these PSAs you're helping Anytown safer for pedestrians.

Thank you for your support.