YOUR INFORMATION

First Name 

Last Name

Cell Phone

Email

STORE SPECIFIC INFORMATION

WHICH NCD DIVISION / DISTRIBUTION CENTER DO YOU WORK WITH?

Please select... CHICOPEE / NORTH / POLEP FARMINGDALE / CENTRAL / HLA PHILADELPHIA / SOUTH / ALLEN BROTHERS ROCKVILLE DC / CENTURY TAMPA / COLONIAL I DON'T KNOW I AM NOT A CURRENT CUSTOMER YET

HOW MANY LOCATIONS/SITES/STORES DO YOU HAVE?

Please select... 1 2-4 5-9 10-19 20-49 50-99 100-199 200+

Which States/Countries do you have stores in?

Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau CanadaSELECT ALL THAT APPLY

Give us one of your store Account #s

Account / Store Name

Store Phone #

ACCRUAL PROGRAM INFORMATION

Did you participate in an NCD MAP program in any prior year through any division
(HLA, Polep, Allen Brothers, Century, Colonial?)

Please select... Yes No Not Sure Other

Do you currently participate in any other distributor's accrual programs?

Please select... Yes No Not Sure Other

Tell us which Distributor(s) Programs you currently participate in...

PAST EXPERIENCE

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
Worth the time and energy
Great selection of programs
The rebate opportunities were tremendous
I was pleased with the brands represented
My sales consultant helped to keep me compliant on the programs

Anything else you'd like to share on your experience?

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