REFERRAL REWARD PROGRAM - QUESTIONNAIRE
DATE
STORE NAME
OWNER NAME
MAILING/ BILLING ADDRESS
CITY
STATE ZIP
PHONE FAX
E-MAIL
WEBSITE
RETAIL STORE YES NO YEARS IN BUSINESS
TYPE OF BUSINESS
PRODUCTS OF INTEREST
E-MAIL THIS FORM TO MIRROR IMAGE STUDIOS
YOU CAN ALSO PRINT OUT THIS FORM AND FAX OR MAIL IT TO:
MIRROR IMAGE STUDIOS, P.O. BOX 280, LEDERACH, PA 19450 Phone (215) 256-0518 Fax (215) 513-0565