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
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
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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