South Jersey Senior Marketing Group Contact List Question Title * 1. General Information First Name: Last Name: Degree / License (if any): Title / Position: Company: Street Address & Suite if any City: State: Zip: Website Address: Question Title * 2. Contact Information Preferred E-mail: Backup E-mail: Cell Phone: Work Phone: Home Phone: Question Title * 3. Please choose one of the following that best represents your primary type of business Adult Day Care Assisted Living Durable Medical Equipment Elder Law Home Health Hospice Hospital Nursing Skilled Nursing Physical Therapy Social Service Visiting Physician Other (please specify) Question Title * 4. Would you like to host an event? Yes, contact me with details Yes, we will contact you when we are ready May be possible in the future No - inadequate meeting space No - limited staffing No - contrary to security protocol Please use this space to explain. Question Title * 5. Would you like to speak at one of our meetings? To speak you must have a topic broad enough to be of interest to most members of the group. It should be educational, not a marketing demonstration. No Not at this time Yes, please provide your topic and a brief description Question Title * 6. Please suggest future presentation topics you'd like covered here. Question Title * 7. Please feel free to provide any comments or suggestions here. For example, are there ways we can make the Networking Group more useful to you, etc. Done