WHeeLz™ TV Order Form - Items in RED are REQUIRED.

STEP 1: About You

This is your CONTACT information for our records. This information does not appear in the commercial. We do not sell or give away your personal information.

First Name:

Last Name:



Unit/Suite/Box #:

City, State, ZIP:

Phone #:

- - Ext.:

Fax #:

- -


Confirm Email:

Business Type:

(This helps us understand your market and potential customers)

1   2   3   4   5  NEXT ->

STEP 2: About Your Product/Service

Information you enter here in Step 2 may appear in your commercial, so double-check spelling, numbers, etc. We are not responsible for misspellings or wrong digits in any information you provide to us.

Name of the product or
service you wish to advertise:

Brief Description:

(tell us, in a few words, what it is)

Your website (if any) - http://

Your 1-800 Toll Free # (if any):

- -

Retail storefront location:
(if "brick & mortar" business)
street address or cross-streets

How will customers buy
your product/service?:

(check all that apply)

at my retail store

online (website listed above)

by phone order (list phone # above)

come to my event


<-BACK  1   2   3   4   5   NEXT ->

STEP 3: Your TV Offer

Script-to-screen, we do it all for you. But we need your input! Tell us what you want us to show on screen, for example, "Join Workout World now, and get 2 months free." It doesn't have to be pretty. We'll dress it up.

* We reserve the option to edit for length, spelling, content, style, and network standards.

Do you already have a TV commercial?

NO - Please make me a brand new TV ad, FREE

YES, ready for WHeeLzTV to air YES, as reference only

(please be as descriptive as possible)

preferred start date:

As soon as possible

date preferred:

Does your company have a SLOGAN that you already use in commerce - online, in brochures, print ads, radio, etc.? (Example: "Wheelies: the Track of Champions")

Company Slogan:

Upload Your Company Logo, if available:

Upload Logo:

<-BACK  1   2   3   4   5   NEXT ->

Almost done!

STEP 4: Your Customer

Tell us about your customer (or your desired customer). This helps us fine-tune your campaign to the right viewers.

I want to reach customers who are... :




Your Customer's Interests:
(check all that apply)

auto buying

auto repair 
















My Custmers
are Located:

Nationwide (United States)

my local area

another local area (specify):


<-BACK  1   2   3   4   5   NEXT ->

STEP 5: Send in your order!

Tell us which package you want, and reserve your spot today!

Choose Your Ad Package:


"The Sporty" - up to 3 mos. airings ($2,999) includes:

  • FREE TV commercial
  • "The Sporty" Plus (check all that apply):

    QuickTime video for your website $149
    Professional Voiceover $199

The Sporty - 3-month air time package

"The Luxury" - up to 6 mos. airings ($5,999) includes:

  • FREE TV commercial
  • FREE QuickTime video
  • FREE Professional Voiceover
The Luxury - 6 month air time package

Language of commercial: English [Free], or Spanish [add $99]

By submitting this form, you agree to our Contract Terms. <-- I AGREE

<-BACK  1   2   3   4   5

When you click “Submit” your order speeds directly to our offices, and you will be taken to the checkout window.

At this time, we request only a one-time reservation deposit of $50 via credit card or PayPal (applicable to your order). The reservation deposit is non-refundable. You will receive an invoice via email for the balance of your order, payable via cashier's check, official bank check or company check. After the balance payment is accepted, production can be completed in as little as 24 hours.

Form version 20080614 © 2001 - Academy Leader, Inc. All rights reserved. Copyrights rabidly enforced.