Prospect Qualification Form

Contact Name:
Company Name:
Ship To:	Name: Address: City: State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Phone: FAX: Email Address:
Bill To Address Same as Ship To Address:	Yes     No

To help us better assist you and learn about your business, please answer the following questions:
1.  Are you the owner of the business?	Yes     No
2.  If you are not the owner of the business, what is the owner's name?
3.  Are you the candy buyer?	Yes     No
4.  Who is the primary contact for placing orders?
5.  Primary type of business:	Drug Grocery Convenience Dollar / Discount Hardware Bakery Food Service Club Wholesale Distributor Vending Military Export Other / Miscellaneous Please Indicate:
6.  Location of business:	Commercial     Residential
Note:  Drop offs are made via semi.  Residential areas may not be shippable.  Please contact us for further details via email at comments@farleysandsathers.com or telephone toll free 1-800-533-0330 and ask for Customer Service.
7.  How did you learn about our company?	Internet   Trade Publication Please Indicate:  Trade Show Please Indicate:  Referral Please Indicate:  Other Please Indicate:
8.  Are you familiar with our products and/or programs?	Yes     No
9.  Are you familiar with our brands/product lines?	Yes     No
10.  Do you currently have a candy program in your store?	Yes     No
11.  If so, what types of packaged confections do you currently offer (please check all that apply)?	Hanging/Peg Bag Clip Strip Laydown Bag Standard Bar/Tube Changemaker Tubs Big Box/Theatre Bucket/Jar Bulk Other
12.  Which of these type of items are you interested in (please check all that apply)?	Hanging/Peg Bag Clip Strip Laydown Bag Standard Bar/Tube Changemaker Tubs Big Box/Theatre Bucket/Jar Bulk Other
13.  Which types of programs are you interested in (please check all that apply)?	Value Line Pre-Priced Premium Brands Seasonal Bulk
14.  Are you interested in our premium, branded items (please check all that apply)?	Heide® Now & Later® Trolli® Farley's® Amazin' Fruit® Bobs® Chuckles® Super Bubble® Rain-Blo® FruitStripe® Hot Dog!® Mighty Bite® Sathers® Brach's®
Additional Comments: