request information

Contact Name:
Company:
Street Address:
City, State & Zipcode
Contact Phone # & Extension:
Fax:
E-mail:
Principal Product or Service Provided by Company:
Total Number of Employees & Management at this Facility:
Number of Employees & Management Interested in On-site Massage (if applicable) :
Payment Option Preferred (check one):	Employer-Paid Employee-Paid Employer/Employee Combination-Paid
Location (check one)	Headquarters Subsidiary
Facility Type (check one)	Production Facility Administrative/Sales/Office Facility Other:

Please note any questions you may have about On-site Massage in the space below. If there are any other branches or locations of your company that you feel would benefit from a program of On-site Massage, please list Contact information.