First Name
    
    Middle Initial
    
    Last Name
    
    Title
    
    Company Name
    
    Street Address 1
    
    Street Address 2
    
    City
    
    State
    
    Zip Code
    
    Country
    
    Phone 1
    
    Phone 2
    
    Fax Number
    
    Pager Number
    
    E-mail Address
    
    Your Web Site URL
    
    Your ID or code, if you know it
    
    Any other information you wish to provide about you or your company
    
    Your line of business
    
    The size of your company
    [ under 5] [ 5-10] [ 10-50]
    [ 50-100] [ 100-500] [ 500+] 
    The size of your sales force
    [ 1-3] [ 3-5] [ 5-10] [ 10-20]
    [ 20-50] [ 50-100] [ 100+] 
    Vertical market you target, if any
    
    The size of your client base
    [ under 10] [ 10-50] [ 50-100] 
    [ 100-500] [ 500-1000] [ 1000+] 
    The percentage of your client base that has expressed
    interest in or is buying Internet services or products
    [ none] [ 1-10%] [ 10-25%] 
    [ 25-50%] [ 50-75%] [ 75-100%] 
    Your current involvement with the Internet for your company
    [ None]
    [ Have only e-mail]
    [ Have Web browsing capabilities] 
    [ Have own web site]
    [ Have in-house web server] 
    Internet services or products you currently sell
    
    Internet services or products you plan on selling
    
    Comments