Mazda North American Operations

Service and Parts

Prior Approval Form

Instructions: Please submit a copy of the ad or a detailed outline of the advertising activity. Retain a copy of this form and any supporting documentation for your records.

Prior approvals may be e-mailed to:

OR

Prior approvals may be faxed to: Mazda Service and Parts (Co-op) 602 431-9713

For additional questions please call your Mazda co-op representative @ 602 438-2320 or E-mail to:

Date Sent: / Time Sent: / Total Pages Sent:

Dealer Information

Dealer Name: / Phone Number:
Dealer Code: / Fax Number:
Dealer Contact: / E-mail Address:

Please enter proposed activity information below

Media Name or Activity Type / Ad From Date / Ad To Date / Estimated Costs
Total

Please allow 48 hours from your initial submission time for The Advertising Checking Bureau, Inc. to review, comment and send back your prior approval request. Once approved, please submit a copy of this signed (by ACB) prior approval form with any related claim materials.

Please provide any additional information that will aid in the approval of the requested activity
The section below is reserved for use by the Advertising Checking Bureau, Inc.

This approval is valid with the following revisions/ requirements:

Approved or Denied / Authorized ACB Signature / Date
N/AApprovedDenied
N/AApprovedDenied
Prior Approval Number

R 040805