Platinum Database Pre qualification form
Customer Information
Company Name Contact Person Name Email
Address City Postal Code
Country Telephone Mobile
Media Vehicle
In-Bound Marketing Out-Bound Marketing eMarketing
facebook facebook
twitter twitter
Linked In LinkedIn
delicious delicious
tweetmeme tweetmeme
Blogs Blogs
rss RSS
stumble stumble
youtube youtube
myspace myspace
slideshare slideshare
mms MMS
Email Email
Fax Fax
SnailMail Snail Mail
Gsm Modem GSM Modem
Bluetooth Bluetooth
Shortcode Shortcode
Isurvey iSurvey
eNewsletter eNewsletter
eBanner eBanner
Xplore Xplore
CellMedia Cell Media
Seo Services SEO
Ds Gradestat DS GradeStat
SalesGenie Sales Genie
Azoogle Ads Azoogle
Wordpress Wordpress
SMS Details
Message Language ArabicEnglishFrenchGerman Message wordcount (characters) 7016070+160+
SMS Count 1 2 3 4 Message Type Songs Ringtone Text Unicode
Message Text
Sender ID Characters Sender ID Language Arabic English French German
Database Details
Specs Client Test Numbers Dataslices Test Numbers Client Database Dataslices Databank Count
Server Log ID (Internal use only)
SMPP IP SMS Gateway No B3A4 A7A4 E3W9 M4X3
Email Details
Html/Text Language Arabic English French German Landing Page Active Non Active Landing Address
Approved By Approved By (Internal Use Only)
Municipality Chabmer of Commerce W3C Media Authority Other
Website Analytics
Yahoo Heatmap Google Double Click Web Stat Webtrend iWebclick Other
Campaign Reasons
Branding Sales Increase General Information Drive traffic to URL Promotions Invitation Alerts Other
Hour 08:00 09:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00
Hour 09:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00
Execution Date
January February March April May June July August September October November December
01 02 03 04 05 06 07 08 09 10 11 12131415161718 19202122232425 262728293031
World Region
Countries Cities
 USA New York Texas Washington California Florida New Jersey Pennyslvania Others / All
 CANADA Ottawa Ontario Quebec Halifax Victoria New Brunswick Edmonton Others / All
 UK London Birmingham Manchester Oxford Cambridge Lanchester Westminster Others / All
 GERMANY Berlin Hamburg Munich Heidelberg Bielefeld Rothenberg Bremen Others / All
 ITALY Roma Perugia Milano Venezia Napoli Bologna Cagliari Others / All
 FRANCE Paris Lyon Marsielle Lille Toulouse Nice Bordeaux Others / All
 AUSTRALIA Sydney Melbourne Brisbane Perth Adelaide Newcastle Canberra Others / All
 NEW ZEALAND Wellington Hamilton Queenstown Christchurch Auckland Dunedin Cambridge Others / All
 JAPAN Tokyo Yokohoma Osaka Nagoya Sapporo Kobe Kyoto Others / All
 CHINA Beijing Shangai Hongkong Tianjin Wuhan Shenzhen Nanjing Others / All
 S.KOREA Soul Inchon Kwangju Pusan Taegu Taejon Busan Others / All
 UAE Abu Dhabi Dubai Sharjah RAK Fujeirah UAQ Al Ain Others / All
 KSA Riyadh Jeddah Mecca Madina Damman Ta'if Tabuk Others / All
 KUWAIT Kuwait City Abdullah Al Salem Al Andalus Bayan Bneid Al-Qar Al Da'iya Al Dasma Others / All
 BAHRAIN Manama Muharraq Riffa Hamad Town Budaiya Jidhafs Adliya Others / All
 QATAR Doha Al Ghanim Al Khor Abu Thaylah Al Jasrah Dukhan Al Mafjar Others / All
 OMAN Muscat Nizwa Ruwi Salalah Sur Ibra Saham Others / All
 EGYPT Cairo Dairut Beni Hasan Aswan Ismailia Damanhur Abu Qirqas Others / All
 LEBENON Beirut Ra's Bayrut Tripoli Sidon Tyre habbouch Joinie Others / All
Database Attributes
Male 13 - 1516 - 1920 - 24 0 - 5000K5001 - 10K10001 - 15K15001 - 20K Arab / MEEuropeanAmericanAustralian
Female 25 - 2930 - 3940+ 20001 - 25K25001 - 30K30001 - 35K35K+ AfricanIndian SubAsianOthers / All
Name:   Dataslices Authority:  
Signature:   Signature:  
Terms & Conditions   : For multi campaigns, seperate forms need to be filled .If web analytics is not implemented Dataslices can provide the same with extra charge .80% Gurranted Reach .Minimum 10 Days are required to submit full report