ADL - The largest and most experienced consulting company in the coin laundry industry

QUESTIONNAIRE

Please supply ADL with the following information so that we can help you with your business needs. Any information that you supply will be held in strict confidence and will not be used for any other purpose except to service your request.

First Name:
Last name:
Company:
Address:
City:
State:
Zip:
Country:
Work Phone:
Home Phone:
Fax:
E-Mail:
URL
Which of the following ADL services are of interest to you:
	Building a new coin laundry
	Purchasing an existing coin laundry
	Selling an existing coin laundry
	Remodeling an existing coin laundry
	Other services
Geographic area of interest:

If you have chosen the United States as your geographical area of interest, please specify the state.

Please provide a brief description of your employment or business background.

Are you a current or past business owner? Please explain.

Have you ever filed for bankruptcy?
	Yes No
What type of investor are you?


Today's Date:	September 2, 2010

QUESTIONNAIRE

First Name:

Last name:

Company:

Address:

City:

State:

Zip:

Country:

Work Phone:

Home Phone:

Fax:

E-Mail:

URL

Which of the following ADL services are of interest to you:

Geographic area of interest:

If you have chosen the United States as your geographical area of interest, please specify the state.

Please provide a brief description of your employment or business background.

Are you a current or past business owner? Please explain.

Have you ever filed for bankruptcy?

Yes No

What type of investor are you?

Today's Date:

September 2, 2010