Electronic Message Request Form

Please review our Electronic Sign Messaging Policy before completing the below form.
The date that you are submitting the application.
Please provide us with an email address so that we can confirm the message information.
Messages are not to exceed 3 lines and 60 characters per line. Note: Southgate will, to the best of our ability, display your message info. It is the responsibility of the originator to ensure that the message displayed is accurate.
*If you selected "Markdale Community Channel" as an option, please provide us with an image you would like on the ad.
*If you selected "Markdale Community Channel" as an option, please provide us with an image you would like on the ad.
If your message is less than a week, put 1 in the field.
Please provide us with a name of the person in the organization that has approved the content of this message.
Please provide us with the position that the person approving the message has in the organization.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.