Please print out the form below and FAX or mail it to: D. DIETRICH ASSOCIATES, INC. PO BOX 379 TELFORD, PA 18969 PHONE: 800-654-8258 FAX: 215-258-1074 HTTP://WWW.DSURVEYS.COM ************* GENERAL INFORMATION ******************************* Name: __________________________________________________________________________ Title: ___________________________________________________________________________ Company: ________________________________________________________________________ Address: _________________________________________________________________________ City: ____________________________________________________________________________ State: ___________________________________________________________________________ Zip Code: ________________________________________________________________________ Phone: __________________________________________________________________________ ************* OTHER INFORMATION ******************************* Please add me to your mailing list: ______ Yes ______ No Please email future announcements to my email address: ______ Yes ______ No Email Address: ___________________________________________________________________ How many people does your company employ? ____________________________________________ During which month does your company perform compensation? _________________________ Comments: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________