Liturature Request Form

Larson & Associates, INC. Customer Satisfaction form & Literature Request Form:

Contact Information:

Your Name: ________________________ Job Function: _____________________

Company: __________________________ Dept: ___________________________

Mailing Address: _________________________________________

______________________________________________________

Telephone: ( ) -

Fax: ( ) -

E-MAIL (If Available): __________________________

Reason for requesting information:

Please Explain what type of information you are requesting:

________________________________________________

General Information:

Have you procured L&A services before? ____ Yes ____ No

Have you filled out this questioner before? ____ Yes ____ No

Have you received product literature before? ____ Yes ____ No

Would you like to receive a brochure? ____ Yes ____ No

Would you like to receive information to your e-mail? ____ Yes ____ No

Was the web site helpful in your search? ____ Yes ____ No

Was your business satisfied with the work performed? ____ Yes ____ No

Why or Why not were you satisfied with the service performed by Larson & Associates, Inc.?

___________________________________________

Any other information or comments?

___________________________________________

Larson & Associates, Inc. appreciates your time in filling out the questionnaire.