Media Discount Request Form

*Required

Name*
Title*
Subject	Media Discount Request
Email Address*
Daytime Phone Number*
Publication*
Editor*
Product Type*
Product Description*
Payment Method*	Credit Card (please call 920-929-5694 with number) Check / Bill me directly Bill my authorized Mercury Marine dealer directly (enter dealership name below)
Billing Address*
Shipping Address*
Sales Tax Percentage*
Product Use*	Magazine/Newspaper Coverage Movie/TV Product Placement Product Comparison/Testing Other (please explain below)
Additional Information
Is this engine replacing an existing engine?	Yes No
Will you need controls or other parts to rig this engine on your boat?*	Yes No If answering Yes, please have your local dealer provide a complete list of quantities and part numbers to order.
Make/Model/Year of existing boat
Mercury Contact