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Name *

Company Name *

Street Address*

Zip Code*

Telephone Number*

Fax Number

Email Address*

Do you market to residents or businesses or both? Residents Businesses Both

Please tell us about your business; what product or service do you offer?*

What level of experience do you have with direct marketing? None Some Experience Very Experienced

How do you plan to deliver your marketing message? Direct Mail Telemarketing Email Marketing

In your own words, please tell who your ideal prospect or ideal customer would be.*

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