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DATA ENTRY FORM

      Customer Details:                
                                                              *Mandatory                                                   
  Business Name *   Other/Corporate Name  
  Contact Name   Description  
 
Local Telephone Number (Area Code + Phone Number)
 
  Main Phone *

*Enter only 10 digit Numbers

  Alternate Phone

 
  Facsimile Phone

  Mobile Phone

 
  Email Address *

*Mandatory

  Email Name  
  Address Line 1 *

*Mandatory

  Address Line 2  
  City *

*Mandatory

  State *

*Mandatory

 
  Zip Code *

*Mandatory

  Country *

*Mandatory

 
             
  Products   Brands  
  Specialties   Areas Served  
  Professional Associations   Year Founded  
  Language Spoken    

      Website/URL address (Example: http://www.infoUSA.com)
  Business Home Page
  Video Link
  Coupon Link
  Social Network Link
  Other

      Photo Link:

      Logo Link:

      Your choices:  
     
  Categories
  Sub-categories

 
 

      Payment Type:
Amex Yes No Diners Club Yes No MasterCard Yes No Discover Yes No
Visa Yes No Debit Card Yes No Store Card Yes No Cash Yes No
Check Yes No PayPal Yes No Invoice Yes No

      Hours of Operation:    
 
Stored as military time - 00:01 - 24:00
 
             
  Monday Open   Monday Close  
  Tuesday Open   Tuesday Close  
  Wednesday Open   Wednesday Close  
  Thursday Open   Thursday Close  
  Friday Open   Friday Close  
  Saturday Open   Saturday Close  
  Sunday Open   Sunday Close