Form

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First name

Last name

Company name

Email*

Phone number

Street address

City

State/Region

In how many States is your product distributed?

Do you currently advertise?

Yes

No

If Yes, what is your average advertising budget per month?

What is your average sale per retail location?

What is Average the re-order frequency per retail location?

1-2 times per week

1 time per month

2 times per month

Less than 1 time per month

Once a quarter