Please provide the following contact information and we will get back to you shortly.  (items marked with an "*" are required):

First name	*
Last name	*
Title
Company Name	*
Street address	*
Address (cont.)
City	*
State/Province	*
Zip/Postal code	*
Country
E-mail	*
Phone	*
Fax

Are you a:

Dealer/VAR?
Consultant?
Restaurant Owner?

If you own a restaurant, what type of restaurant do you own?

Table Service
Bar/Club
Pizza/Delivery

Are you interested in ASI's revolutionary Write-On Handheld^TM?

          Yes
          No

How did you hear about us?

          Web Search Engine.............................................Which one?                 
          Advertisement in Trade Publication......................Which one?

          Received Direct Mail Piece

          Received Email

          Referral................................................................By Whom?

          Other..............................................................Please Specify

Additional comments...?