Thank you for considering Chilcutt Direct Marketing for your list brokerage needs! In order for us to properly assist you we need to obtain some basic information from you.

Your Name:
Company Name:
Phone:
Fax:
E-mail:

The following questions are to help us better assist your personal needs.

What is the nature of your business:
How is your offer related?	Consumer Business
Has your mailing piece been developed?	Yes No
Is this the first time you have ever rented outside lists?	Yes No
What is the total quantity you are looking to mail?
What is your scheduled mail date mm/dd/yyyy?	//
Do you have a house list?	Yes No
If so, what is the size?

Comments and additional information: