Health Insurance Worker’s Comp Biz Owner’s Health Auto Life
Shipping   If you already use UPS, please list your account number so you can become eligible for the USRA Discount and/or so we can insure that you are listed on the USRA/UPS Program

Bank Card Rates   If you already use Bank of America, please list your account number so you can become eligible for the USRA Discount and/or so we can insure that you are listed on the USRA/BofA Program

Educational Seminars
Does your company attend Educational Seminars YES   NO
If yes, How many per year     Last Seminar attended  
What topics would interest you

Does your company attend Trade Shows   YES   Feb   Aug   NO  
Please check all that apply
FN PLATFORM   WSA/ENK   FFANY   GDS   BSTA   MICAM   Atlanta
Sole Commerce    Outdoor Retailer    TRU    Other   

Please complete the following: (Check all that apply)

LOCATION
Strip Center    Indoor Mall    Freestanding    Lifestyle Ctr    Online

NUMBER of STORES
Single Store    Multiple Stores    # of locations

STORE TYPE
Men's    Women's    Website    Specialty   
Children's    Family    Orthopedic    Concept

PRODUCT TYPE
Comfort    Fashion    Dress    Athletic   
Work    Orthopedic    Designer    Medical

RETAIL PRICE POINT
Low to moderate (up to $50)   Moderate ($50 - $150)
Moderate to High ($150-$300)   Over $300

Please include the names/dba's, address's, phone and fax of all additional locations on another sheet.

THANK YOU!!