1) Here’s how you can help me.
(Please pick one.)
I am a conference organizer in need of a speaker.
Name of Conference Conference Date
I am a journalist and would like to speak with you about CRM success stories and strategies.
Name of Publication Story Deadline
I am interested in a partnership with Customer Communications Group.
I’d like to talk about implementing a CRM program within my organization.
(If you choose this option, please answer the following three questions.)
Other (describe)

2) My marketing objectives and responsibilities are:
(Please check all that apply.)
Build loyalty and strengthen customer relationships
Retain customers
Reactivate customers
Acquire new customers/generate referrals
Cross-sell products/services
Increase sales
Differentiate our company from competitors
Reward best customers
Other (describe)

3) We currently communicate with our customers via:
(Please check all that apply.)
Direct mail
Statement-inserted promotions/product offers
Newsletter
Circulars, ROP or inserts
E-mail
Web site
Fax-On-Demand
Other (describe)

4) My areas of greatest need:
(Please check all that apply.)
Customer database segmentation and analysis
Strategic consulting and program design
Creative development and execution
Other (describe)

Thank you for taking the time to provide this information.
I will be in touch with you soon.