Email:
Company Name:
Last Name:
First Name:
Address:
City:
State:
Zip Code:
Telephone:

Would you like a hardcopy of our catalog & literature?		yes
		no
Would you like to receive an e-mail notifying you of current products and promotions?		yes
		no

Are you a:		consumer
		retail store
		wholesaler

If you are a retail store, please check the box that best describes your business: (check all that apply)
Store Front:			Rubber Stamp:
Home Based:			Scrapbook:
Online Store:			Fabric/Quilt:
Art Supplies:			General Crafts:
Office Supplies:			Educational Supplies:
Gift/Party Supplies:			Professional Crafters:
Beauty Supplies:			Home Party:
Chainstore:

Other:

Which Tsukineko products do you use or sell? (check all that apply)
All-Purpose Ink:			Splendor:
Brilliance:			Sponge Daubers
Emboss:			StazOn:
Encore:			VersaColor:
Fantastix:			VersaCraft (Fabrico):
Impress:			VersaFine:
Kaleidacolor:			VersaMagic:
Opalite:			VersaMark:
The Glue Pad:			Walnut Ink: