| Mr
Mrs
Ms
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| *Full Name |
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| Company Name |
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| *Address |
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| *City |
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| State |
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| Country |
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| *Daytime Phone |
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| *EMail Address |
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| I found out about Progreen: |
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| I am looking to potentially invest in your Distributorship program: |
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Immediately
Within 30 days
Within 60 days
Within 6 months
Undecided
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| I am interested in securing a territory in: |
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| I have owned and operated my own business previously: |
Yes
No
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| Amount available for initial investment: |
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$5,000 - $10,000
$10,000 - $20,000
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| Amount available for working capital: |
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$5,000 - $10,000
$10,000 - $20,000
$20,000 - $50,000
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| I will be: |
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Working alone
Working with my spouse
Working with a business partner
Working with a group
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| I will be pursuing this business opportunity: |
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Full time
Part Time
Percentage of Time
In my spare time
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| I have a home office set up and I own the following (mark all that apply): |
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Home Office
Computer
Fax
Accounting and billing software
Sales mgmt software
Truck / SUV
Tools and Equipment
Trailer
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| My Current Occupation is |
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| Please provide a brief summary of your business and professional experience: |
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| I want to purchase a Distributorship and get involved with ProGreen and this industry because: |
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