Contact Request Form

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3907 Keal Run Way

Louisville, KY 40241

(502) 327-0407

Questionnaire

Complete and submit the form. We will get back

to you within hours.

Contact Information

Main telephone number for your company:

Your Web site address:

Are you the person Gersh PR should contact with questions on this communication?	Yes No

Contact name:

Contact title:

Contact phone:

Contact fax:

Contact e-mail address:

Service Requested:*

Who from your company should sign the letter? Please provide the full name and exact title of that person:

Is there someone within your company to whom customer queries should be directed regarding this merger? If so, please provide the full name, exact title, telephone number and e-mail address of that person:

What date do you want this communication released?

Principal/owner of company (full name and exact title):

In how many locations do you do business?

*Name of your company:

Please enter the address of your company:
Address line 1:
Address line 2:
City:
State:
*Postal Code:

Your name:

Your title:

Your phone number:

Your fax number:

Your e-mail address:

How many people does your company employ?

What kinds of products and services does your company provide?

What kinds of customers do you serve -- consumers, businesses, not-for-profit organizations, government entities?

When was your company founded?

Who founded the company?

Name of company:

The address of the company:

Company's Web site address:

Please provide any additional information you would like to include, emphasize or elaborate upon in this communication:

Additional Comments

If you have a moment, we would appreciate any suggestions on how we can make this Web site easier/better for you: