Company Name:

 Your Name:

 Company Address:

 Your Email Address:

 How Did Your Hear About PBM?  Phone Call Recomendation Direct Mail Piece Internet Search Engine Other

 What type of Industry Best Represents The Industry of your company? Print Media Loan Services (Home) Loan Services (Other) Insurance Marketing Charity (Not for Profit) Sales Marketing Medical (Sales) Medical (Other) Other

 Please Check The Type Of Services That You Feel Peconic Bay Marketing, Inc. Could Help Fulfill Your Marketing Needs:

    Outbound Phone Solicitation                                      Database (New or File Cleanup)             

   Direct Mail Design & Services                                     Inbound Phone Services

    Software Design & Networking                                   Web Page Design

    Other

 Type Of Consumer That You Are Trying To Reach On This Campaign? Residential Business Both Other

 What is your goal for this campaign?

 Number of Residences or Businesses You Are Trying to Reach in this Campaign?  (If applicable.) 0-1,000 1,001-5,000 5,001-10,000 10,001-50,000 50,001-100,000 100,001 or more Other

 Timeframe for making a decision? A.S.A.P Within a day Within a week Within the month Whenever, just inquiring

 Your Company Website? (If available)

 Additional Requirements:

 Additional Notes Or Comments:

 When is the Most Convenient Time For One Of Our Representatives to Contact You? Anytime During Business Hours Early A.M Mid Morning Early Afternoon Late Afternoon Other

 What Day is Usually Most Convenient For You? Any Week Day Any Day Monday Tuesday Wednesday Thursday Friday Saturday Sunday