Trucksicle Request Form: Monday to Friday

First & Last Name (of the person who will be our on-site contact day-of): *

Email Address (of the person we are confirming the request/stop with): *

Phone Number (of the person who will be our on-site contact day-of): *

The Date You're Requesting the Trucksicle For: *

The FULL TIMEFRAME within which the Trucksicle could stop by:

Your Requested START Time: *

Hours

Minutes

Your Requested END Time: *

Hours

Minutes

Check only if it appliesYes, I'm also open to other days if the Trucksicle can't make my date above!

Street Address *

Apartment, suite, etc

City

ZIP / Postal Code

Tell us about the event!Is it a special event? A workplace? Soccer Practice? Etc.

How many people are going to be there? (we gotta bring the right amount of popsicles!) *

Any special notes? (parking instructions, where to find you)

Do you consent to the NOW! Trucksicle staff taking and sharing photos of you on social media accounts, @1023nowradio, @nowtrucksicle, our website, 1023nowradio.com and other affiliated Pattison Media Ltd. social media accounts, websites and publications? *Yes, I doNo, I do not, no photos or videos please!

Please Note: