2017 E-Communications Request Form
Today's Date:
Client Name:
Web System(s)

What e-communications template/s do you need?
Do you have a MailChimp account for your department?

Please enter your MailChimp User Name and Password

Enter First and Last Name

Enter the person's Name and E-mail Address
Are there other users who need access to this account?

Do you need MailChimp Training?
Which type of training do you prefer?

MailChimp Acknowledgement
By checking this box, you are confirming that you have read the terms of MailChimp’s free account set-up.