Survey Form:
We are committed to provide you with the highest quality of services and products.
To accomplish this, we need your feedback to help us continually improve our performance.
Please take a few moments of your valuable time to complete this Survey Form.
If you would like to make any additional comments, please do not hesitate to do so.
Just fill the spaces in the bottom of this form.
Your opinions are extremely important to us. Therefore,  we would appreciate your response within the next few days, if at all possible.
Please be assured that any of your personal information and your comments will be confidentially reviewed and addressed by our management team.

Note: All items to be delivered to your home at no extra charge!

First Name:
Last Name
Address: City:   State: Zip
Tel. Number
Fax. Number
E-mail Address:
Note: Information about your family will help us to offer you products and services according to their age range.
Number of family members: Age Range, select ;
 20-30
 31-40
 41-55
 56-65
 66 and up
Number of children:
Children age range, select;
1 month -1 Year,
 1 year -5 years
 6 -10 years
 11-18 years

Would you prefer brand names for paper, plastic goods  or any brand will be accepted as long as they are same quality or higher?
Yes
Would you like to have in your community events like;
1. Fashion, Jewelry
2. Lectures; medical, sports, diet, etc
3. Events for issues related to woman only
4. Lectures, children issues

We are planning to add additional line items:
In order to serve you better, please select type of products you would like to buy on line:

Beads   Paper Goods   Fashion, Apparel, Accessories
Jewelry Lingerie; Accessories Cleaning Goods
Over the counter
(Pharmacy) 		Gifts Perfumes, Skin Care
Baby Needs Small Appliances Bed, Bath, Kitchen
Wedding Needs As Seen on TV Items School Supplies
Vitamins, Health Items Home Improvement Food, Gourmet Food

Please select all services that might interest you: (alphabetical order)

Accounting
Alarm Installation and Services
 Car; Buy, Lease, Rental
 Car / Limousine Service
Carpets, New, Cleaning,    Restoration
Catering (small large events) Hall rental; parties, other events
 Cleaning, House, Windows, etc.
 Cleaning Chimneys, Fireplace
Computer-Software Sales, Services Computer Training
Dating Services
Dog Grooming, Dog Walking
DVD Rental
 Electrical Services
Errand Runners
Film Developing, DVD, CD, VHS production and conversions
 Flowers Delivery
 Furniture Rental
 Insurance, home, car, Jewelry, etc.
 Jewelry and Watch  Repair
 Landscaping
 Laundry, Dry cleaning
Legal Assistance, Referrals
Loans; Mortgage, Equity, etc.
Massage, Personal Trainer at your home
Medical Referral
 Maid, Housekeepers
 Small Appliances Repair; TV, VCR, Kitchen Appliances, Etc
Moving, Relocation
Pest Control
 Photography; Professional/Glamour at home
 Plumbing Services
 Shoe Repair
Storage
 Tent Rental; Parties, Events
 Web Site; Business, Family, Albums, having your family web site including your  family album

If you are looking for other services or products please add it in the next line:

Additional interests, please write  here;

How would you rate the quality of this site?

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How would you rate the navigability of this site?

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Please add any additional comments here, Thank you in advance for your help.

We thank you for your time and effort in helping us improve our services for you, your family, and the community.