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headlines:

*Company Name
*Contact Name
*Title
*Store Name
*Store Address
*Telephone
*Fax
*Toll Free
*E-mail Address
*Federal ID No.
*Resale License No.
*Do you want your invoice copies emailed?	Yes No
*Please list all products sold
*Please list other mailbox manufacturers you sell
*Retail Store area (in Square Feet)
Will you be inventorying product?	Yes No
Do you plan on installing?	Yes No
*Do you have an e-commerce site?	Yes No
Do you advertise in the Yellow Pages?	Yes No
*Other forms of advertisement
*Year business started
*Annual Volume
*Type of business
*How did you hear about Mailboxes Franchise?
*Comments
	*Security Code Message:
	*Read and Accept Terms & Conditions