Name*:

Company Name*:

Company Position*:

Contact Email*:

Contact Phone*:

Mobile Phone:

Contact Fax:

Street Address:

City/Suburb:

State/Province:

Country:

Zip Code:

Industry or Target Market*:

Years in Business*:

Do you already have basic marketing materials?*:
 Yes
 No

Do you already have a web site?:
 Yes
 No

Main Source of New Clients:

Biggest Marketing Challenge:

Do You Have Written Articles Available?:
 Yes
 No

Do You Have Previous Experience With The Media or Public Relations?
 Yes
 No

If so briefly describe the results:

Include any used within the past 12 months

Email Newsletter:
 Yes
 No

Direct Mail:
 Yes
 No

Print Advertising:
 Yes
 No

Writing or Publishing:
 Yes
 No

Referrals or Word of Mouth:
 Yes
 No

Personal Networking:
 Yes
 No

Cold Calling:
 Yes
 No

Public Speaking:
 Yes
 No

Trade Shows:
 Yes
 No

Industry Events & Conferences:
 Yes
 No

Yearly Marketing Budget*:
Please Choose One $2,500-$5,000 $5,000-$7,500 $7,500-$10,000 More than $10,000

How Did You Find Us?*:
Please Choose One Search Engine Another Web Site Newspaper/Magazine Audio Class Read the Book Word of Mouth Other Source

Any Comments or Suggestions?

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