Business / Industry
First Name
Last Name
Job Title
Company Name
Department / Mail Stop
Street Address
City
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State / Province / District
ZIP / Postal Code
Email Address
Business Telephone	ext
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QUALIFICATION FORM

Incomplete forms will not be processed. A complimentary subscription to Storage & Destruction Business will be sent to those applicants who qualify. The publisher reserves the right to limit the number of subscriptions accepted.

1.	I wish to receive Storage & Destruction Business magazine FREE of charge.

Yes!

No

NOTE: In order to be considered for a subscription to Storage & Destruction Business, you MUST select Yes above. If you do not select Yes, you will not receive a complimentary subscription to Storage & Destruction Business.

2.	How do you want to receive your subscription?

Digital and Print

Print only

Digital Only

No Preference

3.	What is your primary business at this location? (check one)

4.	What industry associations are you a member of?

NAID

PRISM

ISRI

EIA

Other, please describe

5.	How many employees do you have?

6.	How many facilities do you operate?

7.	Do you offer on site services?

Yes

No

8.	Do you offer off site services?

Yes

No

9.	What do you offer storage services for? (check all that apply)

Documents

Data

Other, please specify

10.	How many trucks do you operate?

11.	For future renewals, which method do you prefer?

email

fax

phone

12.	Which equipment, products or services are you considering adding or utilizing in the next 24 months? (check all that apply)

1. Shredder

2. Shredding Truck

3. Baler

4. Secure Plastic Containers

5. Secure Consoles

6. Facility Security Equipment

7. Software

8. Employee Background Checks and/or Drug Testing

13.	GIE Media Inc will only use your email address to contact you with relevant industry or subscription information. Do do want to receive email from trusted 3rd parties?

Yes

No

14.	In lieu of a signature, we require a unique identifier used only for subscription verification purposes. What are the last 2 digits of the year you were born?

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