Confidential Employee Survey Proposal Request

Please provide the following information:

Contact Name
Title
Agency Name
Address 1
Address 2
City
State
Zip
Country
Phone
Fax
E-mail Address
Web Site URL
Total Number of Employees:
Number of Locations
Do all employees have easy access to the Internet?	Yes   No
Do all employees have access to Internet e-mail?	Yes   No
If yes, does your e-mail system support HTML format?	Yes   No   Not Sure
*Which type of survey would you prefer?	Internet Based   HTML Email  Hard Copy--Fax/Mail
	*Note:  Internet or E-mail surveys recommended

Please provide any additional information about your agency that you feel may be pertinent when surveying your employees (i.e., any recent management changes, turnover rate over the last two years, etc.)