Full Name (*)

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Company/Business

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Phone (*)

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Email (*)

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For what type of business do you need vending? (*)
Industrial/manufacturing facility (plant, warehouse, etc.)
Office location
Educational institution (school/college/university)
Retail store
Medical facility (hospital/medical clinic/nursing home)
Lodging (hotel/motel)
Restaurant/bar/night club
Other

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Approximately how many people, per day, visit the location where the vending machine will be installed?
Less than 100
100-249
250-499
500+

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Do you currently have vending machines installed in this location?
Yes
No

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How many vending machines do you need in total? (*)
1
2
3+

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What type of vending machine(s) are you interested in? (*)
ATM (Automated Teller Machine)
Toy Plush Cranes
Sport Ball Cranes
Sticker/Tattoo Machines
Bulk Candy Machines
Air Hockey/Video Games

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What is your buying timeframe for this vending machine(s)? (*)
ASAP
One month
Two months
More than two months
Not Sure

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Zip Code of Location (*)

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