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Lupus Radio PSA Registration

Please take a moment to complete the short form below so we may know where our PSAs are being placed. This helps us know who to contact with updates or copy changes.

 

Name: First Last Suffix
Ownership Group / Company:
Mailing Address:
City: State: Zip Code:
Email:
Telephone:
Call letters of the stations on which the PSA will run:
Estimated dates the PSA will run on these stations :
Estimated frequency the PSA will run on these stations:
Type of PSA you will use:
Check this box to join our email list for updates on new PSAs and lupus awareness promotions: .
 
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