HAVE A 1 A VENDING MACHINE REPRESENTATIVE CONTACT ME Thank you for your interest in our Vending Program. To better serve you, please answer the following questions. We will coordinate all activities including the installation of new machines, the removal of current machine if needed, have the machines fully serviced and maintain all at no cost to you. YOUR NAME COMPANY OR ORGANIZATION NAME ADDRESS CITY STATE Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP PHONE NUMBER EMAIL ADDRESS BEST TIME TO CALL 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 AM PM TYPE OF BUSINESS (i.e. apartment complex, office building, retail) HOW MANY MACHINES ARE NEEDED? WILL THESE BE REPLACING EXISTING MACHINES? YES NO DO YOU HAVE OTHER LOCATIONS THAT ALSO NEED MACHINES? YES NO NUMBER OF LOCATIONS HOW MANY PEOPLE PASS BY OR HAVE ACCESS TO THE MACHINE EACH DAY? 1-30 30-60 60-100 Over 100 COMMENTS