LocaliQ - Retail Modification / Cancel Change Order Form
Retail Modification or Cancellation Change Order
Existing
Marketing Materials Information
Company Name (please input EXACT Company Name)
Website
Phone Number
12 characters left.
Street
City
State
2 characters left.
Zip Code
5 characters left.
Campaign Information
Please Select
Modify Existing Campaign
Cancel Existing Campaign
Requested Modifcation Date
Requested
Cancellation
Date
Reason for Cancellation
Which Product is being modified or cancelled?
Service
Parts
Both
Select Service Options Changing
Please select...
All
Auto Recalls
Auto Rental
Auto Repair
Detailing
Diagnostic
Select Parts Options Changing
Please select...
All
Air Filters
Air Flow Sensor
Air Intake
Alternators
Auto Body
Select New Number of Service Records
Please select...
Audience Records 10k
Audience Records 15k
Audience Records 20k
Audience Records 22.5K
Audience Records 25k
Audience Records 30k
Audience Records 35k
Audience Records 40k
Audience Records 45k
Audience Records 50k
Select New Number of Parts Records
Please select...
Audience Records 10k
Audience Records 15k
Audience Records 20k
Audience Records 22.5k
Audience Records 25k
Audience Records 30k
Audience Records 35k
Audience Records 40k
Audience Records 45k
Audience Records 50k
Changes to targeted Zip Codes or radius
Additional Comments or Information
LocaliQ Sales Team
First Name
Last Name
Email
Phone Number
Account Executive
12 characters left.
Sales Leader
12 characters left.
Post Sales Leader
12 characters left.
Client Success Manager
12 characters left.
If you receive an error message from a field that requires an email address, please make sure to remove any spaces before or after the email address.
LocaliQ Internal Information
Adpoint ID Number
Contact Information