First Name:*
Last Name:*
Title:
Organization:*
Number Of Members:*	0-99 100-124 150-174 175-199 200-224 250-274 275-299 300-349 350-399 400-449 450-499 500-549 550-599 600-699 700-799 800-899 900-999 1000-1249 1250-1499 1500-1749 1750-1999 2000-2499 2500-2999 3000-3999 4000-4999 5000-5999 6000 or more
City:*
State:*	AK AL AR AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA ME MD MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VI VT VA WA WI WV WY
Zip Code:*
Phone:*
Fax:
E-Mail:*

(Red * asterisk required)

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Publication Info

					Street Map
					Community Magazine
					Community Profile
					Hardcover Book

How Many Do You Need?					1,000 2,500 5,000 7,500 10,000 More Than 10,000
When Do You Need Them?					Within 3 Months Within 6 Months Within 9 Months Within 12 Months
When Do You Anticipate Making Your Decision?					Within 1-2 Weeks Within 1 Month Within 3 Months Within 6 Months Within 1 Year Just Looking
When Was The Last Time You Did Such A Project?					Within The Last Year 1-2 Years Ago 2-3 Years Ago Don't Know This Would Be The First Time

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Connection Info

					I'm On A Dial-Up Connection
					I'm On A Fast, Broadband Connection Line (DSL, Cable, T1)
					I'm Not Sure

What percentage of your membership is able to recieve your regular e-mail correspondence?

10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

If you had to guess, what percentage of your membership has high-speed internet access?

10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

			Please call me to discuss xMedia publishing options.
			Please send occasional service updates or promotional e-mails.

The more you tell us about your publication needs, the better we can serve you.