U.S. Department of Transportation
Federal Highway Administration
1200 New Jersey Avenue, SE
Washington, DC 20590
202-366-4000
Television Fax-back Form (This sample can be modified for print, radio, etc.)
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
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Number of times you will place the Driver/Young Girl
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Number of times you will place the Driver/Child Crossing
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Number of times you will place the Driver/Child Crossing
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Total estimated value of all placements $
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Your comments
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Name Title
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Station
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Address
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City, State Zip
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Phone Fax
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E-mail
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By using these PSAs you're helping Anytown safer for pedestrians.