Company:

Contact:

Contact Title:

Street:

City:

State:

Zip Code:

Tel:

Fax:

Email:

Website:

Can we add you to our direct mail promotional database? Yes No

Can we add you to our e-mail promotional database?       Yes No

The answers to the following questions will be kept confidential:

What kinds of lists are you interested in:

Business to Business

Consumer

How/Where did you hear about us:

Yellow Page Ad

Internet Web Search

Referral

Publication

Other