CUSTOMER TYPE
*
Retailer
Designer
Hospitality Industry
Consumer
Online Reseller
Wholesaler
Mail Order Catalog
Company Resale Number
Palecek Customer Number
( * Indicates Required Field)
GENERAL INFO
FIRST NAME
*
LAST NAME
*
JOB TITLE
COMPANY NAME
*
WEBSITE
STREET ADDRESS
*
CITY
*
STATE
*
ZIP
*
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
PHONE
*
EXT
FAX
EMAIL
*
FOR RETAILERS
Do you have a retail store front?
Yes
No
How many locations?
1 - 5
6 - 10
More than 10
If you are a retailer, what do you sell?
Furniture
Accessories
Both
Other:
How did you hear about Palecek?
Sales Rep
Showroom
Designer
Email Advertisment
Magazine
Internet
Trade Show
Word of Mouth
Other:
FOR DESIGNERS
What best describes your business?
Designer Showroom
Design Firm
Home Business
Do you purchase for your clients?
Yes
No
What best describes your clients?
Commercial
Residential
Both: Mostly Commercial
Both: Mostly Residential
Does your design business have a store front?
Yes
No
How many locations?
1 - 5
6 - 10
More than 10
How did you hear about Palecek?
Sales Rep
Showroom
Designer
Email Advertisment
Magazine
Internet
Trade Show
Word of Mouth
Other:
HOSPITALITY INDUSTRY
How did you hear about Palecek?
Sales Rep
Showroom
Designer
Email Advertisment
Magazine
Internet
Trade Show
Word of Mouth
Other:
What best describes your business?
Designer
Purchasing Company
Realestate Investment Trust (REIT)
End User
Other:
What best describes your clients?
Hotel
Restaurant
Healthcare
Spa
Time Share
Golf
Other:
INDIVIDUAL CONSUMER
How did you hear about Palecek?
Sales Rep
Showroom
Designer
Email Advertisment
Magazine
Internet
Trade Show
Word of Mouth
Other:
* This website is for the trade only. Please contact us if you have any questiions or for local purchasing options at
info@palecek.com
.
FOR ONLINE RESELLERS
What is your business focus?
Home Decor
Other:
How did you hear about Palecek?
Sales Rep
Showroom
Designer
Email Advertisment
Magazine
Internet
Trade Show
Word of Mouth
Other:
FOR WHOLESALERS
What is your business focus?
Home Decor
Garden/Floral
Restaurant/Hotel Supply
Other:
How did you hear about Palecek?
Sales Rep
Showroom
Designer
Email Advertisment
Magazine
Internet
Trade Show
Word of Mouth
Other:
FOR MAIL ORDER CATALOGS
What is your business focus?
Home Decor
Other:
How did you hear about Palecek?
Sales Rep
Showroom
Designer
Email Advertisment
Magazine
Internet
Trade Show
Word of Mouth
Other:
Catalog Titles:
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