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
*
STREET ADDRESS
*
CITY
*
STATE
*
ZIP
*
COUNTRY
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua & Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire
Bosnia & Herzegovina
Botswana
Brazil
British Indian Ocean Ter
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Canary Islands
Cape Verde
Cayman Islands
Central African Republic
Chad
Channel Islands
Chile
China
Christmas Island
Cocos Island
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote DIvoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Ter
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Great Britain
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guyana
Haiti
Hawaii
Honduras
Hong Kong
Hungary
Iceland
Indonesia
India
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malaysia
Malawi
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Midway Islands
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Nambia
Nauru
Nepal
Netherland Antilles
Netherlands (Holland, Europe)
Nevis
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Norway
Oman
Pakistan
Palau Island
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Island
Poland
Portugal
Puerto Rico
Qatar
Republic of Montenegro
Republic of Serbia
Reunion
Romania
Russia
Rwanda
St Barthelemy
St Eustatius
St Helena
St Kitts-Nevis
St Lucia
St Maarten
St Pierre & Miquelon
St Vincent & Grenadines
Saipan
Samoa
Samoa American
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Tahiti
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Is
Tuvalu
Uganda
United Kingdom
Ukraine
United Arab Emirates
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela
Vietnam
Virgin Islands (Brit)
Virgin Islands (USA)
Wake Island
Wallis & Futana Is
Yemen
Zaire
Zambia
Zimbabwe
PHONE
*
EMAIL
*
CONFIRM EMAIL
*
WEBSITE
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
Are you interested in Designer Services?
Yes
No
Are you interested in Purchasing
Yes
No
Would you like to be contacted by our Preferred Partner to purchase Palecek?
Yes
No
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
Do you buy and stock inventory?
Yes
No
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:
Copyright © Palecek. All Rights Reserved.