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| First
Name: |
* |
| Last
Name: |
* |
| Date
of Birth: |
mm/dd/yyyy |
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Gender: |
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| Email: |
* |
| Tel: |
* |
| Mobile: |
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| Address: |
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| Country: |
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Industry: |
* |
| Occupation: |
* |
| Job
Title: |
* |
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| Level
of Education |
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| Annual
Income |
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| In
what type of business, industry or profession
do you work? |
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| What
is your position? |
Chairman of the Board
President/CEO
Owner/Partner
Director
Company Officer (V.P., Treasurer, etc.)
Manager
Department Head
Supervisor/Foreman
Other administrative position not mentioned
Scientist or Engineer
Technical Specialist
Marketing
Sales
Clerical
Retired |
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| How
many people, including yourself, work at your
company, including branches, international offices
and plants?* |
Under 10
10 - 24
25 - 49
50 - 74
75 - 99
100 - 249
250 - 499
500 - 999
1,000 - 4,999
5,000 - 9,999
10,000 or more |
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| What
are your company’s annual gross sales or
revenues? |
Less than $250,000
$250,000 - $499,999
$500,000 - $999,999
$1 million - $4.9 million
$5 million - $9.9 million
$10 million - $24.9 million
$25 million - $99.9 million
$100 million or over |
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| What
year did your business start?
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Do
you serve on your company's board of directors?
Yes
No |
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Are
you on the board of directors of any other company
Yes
No |
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Are you an owner or a partner of a business?
*
Yes
No |
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| If
you answered yes to the previous question, in
what industry or profession were you employed
and what was your job title before you became
an owner or partner? |
Industry
or Profession:
*
Job Title:
* |
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Are
you considering starting or buying a new or
additional business?*
Yes
No |
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| If
you are planning to start or buy a new business,
when do you plan to do so?* |
In the next six months
In 7 to 12 months
In 13 to 24 months
More than 24 months from now
Not sure |
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| Would
you like Business Unlimited’s consultants to talk
to you about a particular issue? * |
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*
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| Username |
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| Password |
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