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Your Name
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Company/Account Name
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Email Address
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Phone Number
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Do you currently have a permission-based email list of contacts?
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Yes
No
If yes, how many contacts?
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0-500
501-2,500
2,501-5,000
5,001-10,000
10,001-15,000
15,001-25,000
25,001-50,000
How often do you plan on sending out an email?
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Weekly
Bi-weekly
Monthly
Bi-monthly
Additional Comments
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Type out exactly as shown
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