First
Name:
*
Last
Name:
*
Date
of Birth:
mm/dd/yyyy
Gender:
Male
Female
Email:
*
Tel:
*
Mobile:
Address:
Country:
Albania
Algeria
Angola
Anquilla
Antarctica
Antigua
and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Belgium
Belize
Benin
Bequia
Bermuda
Bolivia
Bosnia
and Herzegovina
Brazil
Brunei
Bulgaria
Burundi
Cambodia
Cameroon
Canada
Central
African Republic
Chile
China
Columbia
Commonwealth
of Dominica
Congo
Costa
Rica
Croatia
Cuba
Cyprus
Czech
Republic
Denmark
Dominican
Republic
Dutch
Antilles
Ecuador
Egypt
El Salvador
Estonia
Ethiopia
Fiji
Finland
France
French
Antilles
French
Polynesia
Georgia
Germany
Ghana
Gibraltar
Great
Britain
Greece
Guantanamo
Bay
Guatemala
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle
of Man
Israel
Italy
Ivory
Coast
Jamaica
Japan
Jordan
Kenya
Kuwait
Laos
Latvia
Lebanon
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Malawi
Malaysia
Maldives
Malta
Marshall
Islands
Mauritius
Mexico
Monaco
Montserrat
Morocco
Mozambique
Mustique
Myanmar
Namibia
Nepal
Netherlands
Nevis
New Zealand
Nicaragua
Nigeria
North Korea
Northern
Ireland
Norway
Oman
Pakistan
Palm Island
Panama
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Romania
Russia
Saudi Arabia
Scotland
Senegal
Singapore
Slovakia
Slovenia
South Africa
South Korea
Spain
Sri Lanka
St. Kitts
St. Lucia
St.
Vincent and the Grenadines
Suriname
Sweden
Switzerland
Syria
Taiwan
Tanzania
Thailand
Tobago
Trinidad
Tunisia
Turkey
Uganda
Ukraine
Union Island
United
Arab Emirates
United States
Uruguay
Vatican City
Venezuela
Vietnam
Virgin Islands
Wales
Yeman
Yugoslavia
Zaire
Zambia
Zimbabwe
Industry:
*
Occupation:
*
Job
Title:
*
Level
of Education
Not
attended High School
Attended
High School
Graduated
High School
Attended
College
Graduated
College
Post-Graduate
Study Without Degree
Post-Graduate
Degree
Annual
Income
Less than
$30,000
$30,000
- $39,999
$40,000
- $59,999
$60,000
- $74,999
$75,000
- $99,999
$100,000
- $149,999
$150,000
- $249,999
$250,000
- $499,999
$500,000
- $999,999
$1 million
or more
In
what type of business, industry or profession
do you work?
Agriculture/forestry/construction
Data
processing/computers
Finance/banking/insurance
Health
care (medical, dental, etc.)
Real estate
Wholesale
trade
Retail trade
Communications/publishing/advertising
Consulting
Education
Government/public
administration
Manufacturing
Personal/business
services (consultant, CPA, lawyer, etc.)
Other
What
is your position?
Chairman of the Board
President/CEO
Owner/Partner
Director
Company Officer (V.P., Treasurer, etc.)
Manager
Department Head
Supervisor/Foreman
Other administrative position not mentioned
Scientist or Engineer
Technical Specialist
Marketing
Sales
Clerical
Retired
How
many people, including yourself, work at your
company, including branches, international offices
and plants?*
Under 10
10 - 24
25 - 49
50 - 74
75 - 99
100 - 249
250 - 499
500 - 999
1,000 - 4,999
5,000 - 9,999
10,000 or more
What
are your company’s annual gross sales or
revenues?
Less than $250,000
$250,000 - $499,999
$500,000 - $999,999
$1 million - $4.9 million
$5 million - $9.9 million
$10 million - $24.9 million
$25 million - $99.9 million
$100 million or over
What
year did your business start?
Do
you serve on your company's board of directors?
Yes
No
Are
you on the board of directors of any other company
Yes
No
Are you an owner or a partner of a business?
*
Yes
No
If
you answered yes to the previous question, in
what industry or profession were you employed
and what was your job title before you became
an owner or partner?
Industry
or Profession:
*
Job Title:
*
Are
you considering starting or buying a new or
additional business? *
Yes
No
If
you are planning to start or buy a new business,
when do you plan to do so?*
In the next six months
In 7 to 12 months
In 13 to 24 months
More than 24 months from now
Not sure
Would
you like Business Unlimited’s consultants to talk
to you about a particular issue? *
Marketing
and Sales Management
Expansion
or sale of Business
Organization
Management
Franchising
of Business
Production
Management
Human
Resources Management
Financial
Management
CRM Strategy
Software
Solutions
Web Solutions
ISO – Systems
*
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