APPLICATION FOR AIRTIME

APPLICATION FOR AIRTIME

BIRACH BROADCASTING CORPORATION

21700 Northwestern Hwy * Tower 14 * Suite 1190 * Southfield, MI 48075

http:// www.birach.com Tel: 248-557-3500 Fax: 248-557-2950

Applying for airtime at radio : ______________________________________________________

Program name: ___________________________________________________________________

Director name: ____________________________________________________________________

Address: __________________________________________________________________________

Telephone: work _______________________ home ____________________________

fax ______________________ pager ____________________________

SS # _____________________ DL # ____________________________

Preferred Day's

MONDAY - TUESDAY - WEDNESDAY - THURSDAY - FRIDAY - SATURDAY - SUNDAY

Hour's

1^st choice ________________ 2^nd choice ________________ 3^rd choice________________

Remarks:

______________________________________________________________________________________________________

______/____/_______ ___________________________

date signature

FILL IN THE REQUESTED INFORMATION AND FAX THE APPLICATION TO FAX NUMBER 248-557-2950