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Name:
Title:
Company:
Address:
Street City Zip
Telephone/Fax:
Telephone Fax
E-Mail:
Hours of Operation:
Best Time to Meet:
Number of Persons Likely to use the Machines :
Employees Customers
Check if Interested in Commission Based on
Price of Items :
Yes, interested in Commission
Presently Have Machines:
If yes:
How Often are they Refilled?
Primary Complaint with Existing Machines:
Would you Like a No Obligation Proposal from Rixy Vending Corp.?
Comments: