VersaSeal

ò Simply complete this application. There is no obligation and the information is strictly confidential..
ò This application will be used to determine if you qualify for the Free VersaSeal equipment offer.
ò After you complete this application, we'll contact you and provide a free overview of your current situation and proposed solutions.
ò We will advise you of the status of your application via e-mail to the address you provide below.

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Please tell us how you learned about this offer. Select from the following options:

*Organization/Business Name:

*Contact Person:

First Name: Last Name:

*Contact Title:

Please specify:

*Contact E-mail:

Confirm Email:

*Business Phone:

- - ext:

Secondary/Cell Phone:

- - ext:

Fax:

- -

*Business Address:

Business Name:
Address1:
City:		State:
Zip:

Shipping address:

Physical address for printer shipment (no PO Boxes)

My shipping address and business address are the same
Shipping Address:
Shipping City/State:
Shipping Zip:

Organization Website:

*Information about the organization where the folder sealer will be used:

*Amount you spend on printing supplies and services:

*Brands of printers you currently have: (check all that apply)

Hewlett Packard Lexmark Minolta/QMS
Tektronix Xerox Other

*Who do you consult about your printing needs:

*Please confirm your monthly usage for the following products. Please be sure to estimate these numbers as accurately as possible. Your usage will determine your eligibility for this program. Some commitment may be required prior to installation

$ Checks or Direct Deposit		$ Tax Forms
$ Forms (statements, invoices, purchase orders)		$ Educational Forms (grade reports, transcripts, notices)
$ Financial Forms (checks, notices, tax forms)		$ Direct Mail Applications
$ Brochures/Newsletters		$ Retail Forms (checks, tax forms, frequent buyer mailings or cards)
$ Applications for Membership; Renewal Notices		$ Other

I would like to receive other information about VersaSeal products and services:

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Please enter the e-mail addresses of others you would like to tell about this program: