Info Request

To receive additional information on Allegiant Direct and its services, please complete the following:

Name:

Title:

Organization:

Address 1:

Address 2:

City: State: Zip:

Telephone:

E-mail:

Web Site:

Number of Active Donors (gift in the last 12 months):

Total number of Lapsed Donors (last gift prior to previous 12 months):

Number of In-House Prospects:

Other in-house prospects & quantities (such as alumni, Senior Wellness groups, employees, volunteers, etc:

Have you ever used rented lists? Yes No

Please provide the first three digits of the zip codes in your primary and secondary market area:

Primary market area:

Secondary market area:

Number of colors in your logo: One Two Three What is your fiscal year? Calendar Year Fiscal Year Areas of interest (click all that apply):

Donor Acquisition Donor Renewal Membership/Giving Clubs Lead Generation Internet Telemarketing

FOR HOSPITALS ONLY:

Do you mail to former patients? Yes No

Total number of unique patients age 60+ annually (individuals, not total number of visits): :

Comments: