| First Name |
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| Last Name : |
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| Address : |
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| City : |
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| Country : |
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| Province / State : |
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| Zip / postal Code : |
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| Company : |
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| Position : |
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| Number of locations : |
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| Number of employees at your location : |
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| Telephone : |
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| E-mail Address : |
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| What is the best time of day and method to reach you? : |
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| Does your company presently use anti-fatigue floor matting ? : |
No |
| If yes , how much is your annual matting budget ? : |
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| Do you have a preferred footwear or safety product distributor ? : |
Yes
No |
| If yes, who is the distributor ? : |
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| Does your company presently have a safety footwear program in place ? : |
Yes
No |
| -- If yes, how much is paid for by the company ? : |
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| What is the most common type of footwear worn at your Facility ? : |
Casual/Shoes
Industrial/Boots |
| Does your company presently provide insoles/orthotics ? : |
Yes
No |
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| What
benefits form flooring matting or shoe insoles and orthotics are you
most interested in achieving ? (Please check all that apply) : |
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| Has
your company ever conducted an evaluation program in regards to floor
matting, insoles/orthotics and worker comfort and fatigue ? : |
No |
| Size Requests : Preferred Size (we will try our best to accommodate) : |
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| Other Special Requests or Relevant Information : |
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