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WHAT STEPS DO I TAKE TO BECOME A
QUIK INTERNET MASTER FRANCHISE OWNER?

 

  1. You have taken the first step by requesting information. You should read the material and write down any questions you have. If you are on the Internet now, please print off and read all of the pages at our web site which is http://www.quik.com/007  
  2. If you are serious about this opportunity you should complete the Qualification Profile form and mail it to our West Coast Operations Office.
  3. Please call us and we will conduct a telephone interview with you in an attempt to discover first, if this is something you are able to do and second, if we feel you will make a successful master franchise owner. If we feel you are qualified we may arrange a personal interview with you . One way or the other, we will answer any questions you may have.
  4. After the interview, if both parties feel it appropriate, you will have a chance to temporarily tie up a specific territory by completing a Franchise Territory Reservation Application and submitting a $5,000.00 USD refundable deposit. This indicates your commitment and causes us to stop marketing that area on a temporary basis.
  5. Upon receipt of your deposit we will hand to you or send to you our Letter of Intent and Franchise Agreement. Within 30 days our operational analysis for your area will be complete.
  6. During this 30 day period our executive committee will thoroughly investigate you as a potential franchise owner and will either approve or reject your application. You will be notified either way within 48 hours of their decision. If rejected, your deposit is returned immediately.
  7. Upon approval of your application and receipt of your franchise fee, Quik International will schedule your training and assist you in the additional necessary steps to get your site up and running.
  8. You will be scheduled into a 5 day training seminar usually held in Las Vegas, Nevada or Southern California. We may elect to conduct the 5 day training seminar at your location.
  9. Your site equipment package will be ordered and set up by our technical department.
  10. When your telephone lines and T1 line is installed we will do the equipment installation and assist you in your franchise opening procedures.

Welcome...

Dear Fellow Entrepreneur

Quik duplicates its U.S. franchise system in foreign countries through two programs. First, Quik International licenses independent franchise units in a geographic territory. This model follows the same operations as our domestic unit franchise program. What this means to you is you can start your operation in a very short time while saving a significant amount of your investment.

Second, Quik International grants Master Franchise Agreements. What this means to you is Quik contractually allows the Master Franchise owner to replicate the proprietary system and channel industry products to end users. The Master Franchise owner is granted the right to sell and support sub-license units within an Exclusive Territory. The Master Franchise owner then relies on Quik for technical assistance, training, equipment purchasing, Internet and Intranet products, consulting services, trade marks and marketing materials of Quik International. Furthermore, this program allows the Master Franchise owner to concentrate on the greater business opportunity within the county while leveraging Quik’s existing expertise and proprietary systems. Quik’s Master Franchise program allows the Master Franchise owner to share significantly in franchise fees and royalty fees as the territory is developed.

Quikis responsible for administration of the company’s World Wide franchising program, including:

Thus far, Quikhas several International relationships in place and the International opportunities are the fastest growing segments of the Quik operation.. Quik Internet is an established organization of independent retailers of Internet/Intranet products and services.

To summarize, Quik is a company of accomplished Internet professionals, many of who have owned and operated their own successful businesses including Internet service companies. Quik Internet franchise owners and Master Franchise owners both enjoy the following benefits:

The current fee for a single unit international franchise is USD$45,000. The Master Franchise fee ranges from approximately USD$50,000 to USD$1.25 million depending upon the population and other social-economic demographics of the desired area plus additional franchise fees as outlined in our licensing agreement. Master Franchise agreements are being offered on a first come first serve basis to qualified persons and organizations.

We have the technology and business partners. You have the contacts and access into your country.  We feel comfortable that this is a very good combination. If this is of interest to you and you have the investment capital, please read the pages ahead and then submit the online forms.  To facilitate an open dialogue you will be required to execute a Confidentiality Agreement and submit a refundable evaluation fee of $5,000 US.  We await your response.

 

Sincerely,
Garic O'Brien
+1 (940) 723-8085
Ron Vincent
+1 (212) 620-7116

Murray Mead
+1 (949) 548-2171

Description

THE FRANCHISE OF THE FUTURE

Quik International (Quik) is the first franchisor of Internet access services. In the last 26 months, it has established over 100 franchises in the United States, Guatemala, El Salvador,   Russia, Canada, United Kingdom, New Zealand, Australia, Puerto Rico, Dominican Republic, Venezuela, and now Mexico. These franchises operate as locally owned and operated Internet Service Providers (ISPs) in their respective markets.

Central to Quik's success has been its development of a proprietary technology called "Cheetah." This technology greatly simplifies the process of selling and administering Internet services. Anyone with a good working knowledge of Windows95 has all the skill and comprehension necessary to attend a Quik franchisee training seminar and become a successful franchise owner.

The company owns and operates an International data transmission network which consolidates all the Internet traffic from its franchises into central servers. Quik owns and maintains the equipment that is connected to three Internet backbone providers.

All of Quik's franchises time-share on a variety of computer equipment that is owned and operated by Quik. These computers provide user authentication, DNS, email, world-wide-web, USENET and billing services for all of the franchise owners.


Locations

franchguate.gif (30525 bytes)
Quik Internet of Guatemala

Quik Internet franchises opened for business in the following order:

Reno, NV July 1996 Rockford, IL July 1997
Salt Lake City, UT July 1996 Boston, MA #2 August 1997
Las Vegas, NV August 1996 Charleston, SC August 1997
Palm Beach, FL August 1996 McAllen, TX August 1997
Huntington Beach, CA August 1996 Buffalo, NY September 1997
Irvine, CA August 1996 Portland, OR September 1997
Las Vegas, NV #2 September 1996 Moscow, Russia October 1997
Riverside, CA September 1996 Phoenix, AZ February 1998
NE Dallas, TX October 1996 Vancouver, BC, Canada February 1998
NW Dallas, TX October 1996 Green Bay, WI March 1998
Anaheim, CA November 1996 North San Diego, CA March 1998
Denton, TX December 1996 Mitchell, IN March 1998
Wichita Falls, TX December 1996 El Salvador March 1998
Guatemala City, GT January 1997 Provo, UT April 1998
Orlando, FL January 1997 Salt Lake City, UT #2 April 1998
Burbank, CA January 1997 Boston, MA #3 May 1998
Melbourne, FL February 1997 Charlotte, NC May 1998
Centralia, WA May 1997 Midland, TX May 1998
Boston, MA June 1997 Denver, CO May 1998
Colorado Springs, CO June 1997 Austin, TX May 1998
Rogers, AR June 1997 Camden/Cherry Hill, NJ May 1998
Long Beach, CA June 1997 Houston, TX May 1998

Continued...

Wellsboro, PA May 1998 Houston West, TX Nov. 1998
Spartanburg, SC May 1998 Houston East, TX Nov. 1998
Surrey, BC, Canada May 1998 Dominican Republic Nov. 1998
Western Canada, Master May 1998 Raleigh, NC Nov. 1998
Baton Rouge, LA July 1998 Windsor, ON, Canada Nov. 1998
Houston, TX #2 July 1998 Manhattan, NY Nov. 1998
Boulder, CO August 1998 Manhattan, NY #2 Nov. 1998
Atlanta, GA August 1998 Nashville, TN Nov. 1998
Arcata, CA August 1998 Venezuela, Master Nov. 1998
Modesto, CA August 1998 Leicester, England Nov. 1998
Queens, NY September 1998 Newcastle, England Nov. 1998
North Houston, TX September 1998 San Diego, CA #2 Dec. 1998
Long Island, NY September 1998 San Diego, CA #3 Dec. 1998
Arlington, VA September 1998 San Diego, CA #4 Dec. 1998
Louisville, KY September 1998 San Diego, CA #5 Dec. 1998
Lexington, KY September 1998 Northwest, CO Jan. 1999
New Orleans, LA September 1998 Edinburgh, Scotland Jan. 1999
Ontario, Canada, Master September 1998 Mexico, Master Jan. 1999
United Kingdom, Master September 1998 Aukland, New Zealand Jan. 1999
San Juan, Puerto Rico October 1998 Wellington, New Zealand Jan. 1999
San Juan, Puerto Rico #2 October 1998 So. Goldcoast, Australia Jan. 1999
San Juan, Puerto Rico #3 October 1998 Virginia Beach, VA Feb. 1999
Australia Master October 1998 Ponce, Puerto Rico Mar. 1999
New Zealand Master October 1998
Vancouver, BC, Canada #2 Nov. 1998

U.S. Management Team

Jack Reynolds, President - has served in executive level positions at Compaq Computer, Tandon, AST Research, Everex and ACER. During his 15 years in the computer industry, Jack has had national and international responsibility for product distribution through computer resellers such as Computerland, Microage, Ingram Micro, Sears and Inacomp. His interest in the Internet began in 1985 when he used Internet tools to manage software product development in Germany from the United States. Jack opened up several Internet sites in Southern California for other companies under contract in 1994 and opened up a prototype for what would become a Quik Internet site in his garage in 1995.

Murray Mead, CEO - has 30 years of franchising experience to his credit. He has successfully franchised swimming pool companies, restaurants and financial services. Murray has an extensive background in executive management in everything from start-up companies to national hotel chains. Murray became interested in the Internet when the World-Wide-Web was first developed in 1994. He is the architect behind Quik's business model of local Internet service and support delivered through entrepreneurs in their respective communities.

Griff Hamlin, VP of Technical Services - is Quik's Webmaster , a contractor of 3D graphics software and Web-hosting services. With more than 20 years experience in several areas of computing, his list of accomplishments is considerable including graphics hardware and software design, 3D CAD software design and the creation and international distribution of "Math Type," a mathematical equation editor available in four languages and used in Microsoft products. Griff also founded a number of computer service companies after earning a Ph.D. in computer science and has been a college professor. Dr. Hamlin's career has affiliated him with the NASA Langley Research Center, Los Alamos National Laboratory in New Mexico, Unicad Software in Bolder, Colorado and Stellar Computer in Massachusetts.

"Quik’s great franchise support allows me to spend more time supporting my customers" says John Nance, owner of Quik Internet of Reno, "By pooling my resources with other Quik franchise owners, I lower my cost of doing business and stay on the front of the technology curve."


Quik Internet Products and Services

Internet Access ( 56 K )

Internet Access (ISDN)

Internet Training

Basic Website

Features:

URL is:
10 megabytes disk space.
100 Mb/month WWW traffic.
Unlimited Hits.
Customer creates/maintains web-pages.
FTP access to server.

Cost: No extra charge, comes with Quik dial-up account.

Basic Virtual Website

Features:

10 megabytes disk space.
Domain name. URL will be: 
500 Mb/month WWW traffic.
Unlimited Hits.
Customer creates/maintains web-pages.
FTP access to server.

Deluxe Virtual Website

Features:

50 megabytes disk space.
Domain name. URL will be: http://www.customer_name.com.
Unlimited* WWW traffic.
Unlimited Hits.
Customer creates/maintains web-pages.
REALAUDIO server for streaming audio
3 POP email boxes. 
Unlimited email forwarding.
FrontPage Extentions
"Hit" statistics.
CGI Scripts

Premium Virtual Website

Features:

100 megabytes disk space.
Domain name. URL will be:
Unlimited* WWW traffic.
Unlimited Hits.
Customer creates/maintains web-pages.
REALAUDIO server for streaming audio
VDO Server for streaming video
Unlimited POP emailboxes.
Unlimited email forwarding.
FrontPage Extentions
"Hit" statistics.
CGI Scripts
Shell account
SSL and server authentication

Virtual Machine

Features:

Ideal for Website Resellers.
Includes 10 Premium Virtual Websites
For resale only.
No end-user support.
Customer creates/maintains web pages.

*Quik Internet reserves the right to review content.


training.gif (31428 bytes)

Quik conducts five day intensive training seminars

Quik operates a franchise site in every location in which it offers services. The key to its success is that it offers local service and support from entrepreneurs in the local community. Quik's services are, in fact, very similar to those offered by other ISPs. The important differences are realized in its localized availability and specialized support.

The Internet is a decentralized communications network that is best supported by a decentralized business model. Franchising gives entrepreneurs the economies of scale and brand name recognition they need in order to compete with large centralized Internet service providers like the phone companies. Service and pricing being equal, people will always do business locally with people they know.

A typical subscriber recently wrote:

"Dear Jack: I am most pleased with my Quik account. I recently switched over from Netcom and the difference is amazing. I have yet to experience any log-on delays due to busy signals or whatever, and the speed of the connection blows me away. Thanks again for the prompt reply".


Industry Analysis

We are interested in reviewing applications from persons who are able to see an opportunity, enjoy working, are people oriented, have a working knowledge with computers and want to own and operate their own business. You must have the ability to invest approximately $70,000 plus working capital.

Franchising has long been recognized as a proven vehicle for:

A. Raising capital rapidly in industries that require a large investment in facilities.
B. Recruiting highly motivated talent that has a vested interest in the success of the company.
C. Providing focused local presence in industries that are geographically diverse.
D. Quickly building brand-name recognition for products and services.

The above components all apply to Quik's strategy. However, there are additional factors at play in the Internet business that further reinforce Quik's Internet franchise model:


Cheetah

Simplifying the Delivery of Internet Services

A primary barrier to deployment of Internet products and services is that they require a high degree of technical knowledge to implement and maintain. There are simply not enough people who understand UNIX system administration, IP addressing and routing, domain name service, and wide area networking using the telcos (to name a few of the technical issues). In order to cross the bridge between our franchise owner’s limited technical knowledge and the high degree of technical knowledge required to sell and support Internet services, Quik created Cheetah.

Cheetah Site Management Software

Quik has developed a browser-based software package for the franchises that automatically configures and maintains their accounts and services. This enables them to run every part of their business from any browser from any location on the Internet. All they need is the right password.

The following options are available on the Cheetah home page:

A. Add a new Basic account.

1. Adds the dial-up access.
2. Adds the email address.
3. Adds the website.
4. Initiates the billing.

B. Delete a Basic account.

1. Deletes the users account.
2. Tracks the reason for quitting.

C. Add a new Virtual Web-site.

1. Adds a virtual site to the server.
2. Assigns the site a dedicated IP address.
3. Sends the registration email to Internic.
4. Initiates the billing.

D. Delete a Virtual Web-site.

1. Deletes the virtual site on the webserver.
2. Sends the email to Internic to cancel the registration.
3. Re-allocates the IP address.
4. Tracks the reason for quitting.

E. Add a new Virtual Machine Web-site.

1. Configures the server for 20 domain names.
2. Allocates 20 IP addresses to the customer.
3. Notifies the webmaster via email.
4. Initiates the billing.

F. Add an additional email box to an existing account.

1. Adds an additional email box for a user.
2. Adds $5.00 per month to the customer billing.

G. Delete an additional email box.

1. Deletes user email box
2. Tracks reason for deletion.

H. Modify your franchise e-mail forwarding addresses.

1. Allows franchise to forward email to any address.

I. Your Router.

1. Shows who is online.
2. Allows franchisee to knock people off-line.
3. Shows modem traffic.
4. Shows T1 traffic.
5. Remote reboot

J. View customer usage.

1. Shows time and date of all logins
2. Shows amount of data transferred by each customer.

K. View customer billing.

1. Shows customer billing amount along with fee schedule.
2. Automatically debits accounts on appropriate days.
3. Shows all account credits.
4. Ages all accounts.

L. Your Customers.

1. Lists all customer information.
2. List individual customer.

Cheetah software enables a franchise owner with average knowledge of Windows95 to be able to configure and maintain all common Internet services after five days of training. A franchise can train a Quik Agent to configure basic access, email and web accounts in two hours.

Cheetah also has an end-ures component. Configuration CD-ROMs for Window95 allow an end-ures to configure their Internet account automatically update and install Microsoft Internet Explorer 4.0.

Quik’s proprietary Cheetah Site Management software is an example of Quik’s dedication and ability to keep Quik Internet franchise owners on the cutting edge of new developments and technologies in our fast changing business.


Internet Education for The Public

A July report from American College Testing, a surveyor of 2,564 colleges and universities, found that the first-year dropout rate at private colleges rose to 26 percent, up three points since 1983.

In a recent survey conducted by the Olsten Forum on Human Resource Issues and Trends, more than half of the company executives surveyed said their employees' lack of certain skills resulted in increased production costs. More interesting still, these same companies, while acknowledging a deleterious skills gap in workers, scaled back their in-house training programs.

While no positive inference seems possible from these reports, both surveys uncovered the common fact that increased computerization was leading the drive for increased basic training in computer skills. The question still remains, however: Who will deliver the necessary training, and how?

Quik sees such gap in skills as an opportunity to participate at the community level by providing basic computer training through its franchise network and, at once, encouraging new access customers to choose Quik before they are influenced by other national providers. Indeed, to Quik, the perfect access customer is one who has benefited by our network of community "information outreach" in advance of becoming a customer. They will have already participated in a local Internet Training meeting or attended a basic skills workshop conducted by the local Quik franchise owner.

A two-point strategy, advanced by Quik management, includes maximizing ease-of-use of all systems and equipment, whether by franchise owner or end-users, and providing accessible, topical and affordable (often free) basic computer training to customers and non-customers alike.

One of the most successful training forums in Quik's growing arsenal is the user-group meeting, a collection of Internet customers linked by community geography through their Quik Internet service provider. Typically, the Quik ISP will hold one meeting a month until demand from a growing base of customers, driven largely by regular user-group meetings, requires multiple meetings in order to contain the size for maximum effectiveness and participation by attendees.


QuikNET

QuikNET is an International Internet communications network designed, built, and maintained by Quik. QuikNet is specifically designed to carry Internet traffic for geographically dispersed ISPs and their customers. It is the only Internet network we are aware of that separates server traffic from access traffic. The savings to Quik's franchise owners is huge.

QuikNET Architecture

The main gateway for network traffic is in Australia. This is where QuikNET links to first tier Internet backbone provider. In addition we have connections to public Internet exchanges at MAE-LA and MAE-West as well as Internet ports from BCTell in Vancouver, Canada, and BBN Planet and UUNet in the United States. The links to the remote cities are accomplished by using a virtual private network (VPN) from WorldCom and Sprint.

The network is supported by IBM RS/6000 servers in Canada, the United States, Guatemala, United Kingdom, New Zealand, and Australia. These servers are used by the Quik franchises exclusively. They support Cheetah, DNS, USENET, email, WWW, FTP, and Unix shell accounts. Sharing centralized Quik servers reduces by 70 percent the capital equipment expenditure needed to start an ISP. The average ISP spends $150 per customer on hardware and software. A Quik franchise owner spends $18 per customer on capital equipment and software.

Average up-time for QuikNET (communications and servers included) is more than 99.9 percent.


Target Markets

Quik is targeting successful entrepreneurs who have good people skills. Almost all of the current Quik franchise owners have operated successful businesses in the past. 15 percent are currently active with other franchisors in other industries.

If you believe, as we do, that the Internet is a watershed event in it’s Model T development stage, have the  investment capital and feel qualified to develop a Quik Internet franchise, we want to talk to you right away. We can help you get your share of the profits to be made as the information Superhighway develops. You can send us information on yourself by filling in the online form following this page, or call us at 02/ 66 287 644.

In business, as in sports, the ones making all the money are on the playing field. Don’t let this revolution leave you watching.


"We plan to be the McDonalds of the Internet business."


Personal Profile

Date:
E-mail address:
Name: Name of spouse:
Day phone:
Evening (home) phone:
Address:
City:   Postal Code:

 

Which Quik Representative referred you to this site?

Are you willing to follow our established franchise devolpment proceedures?
YES NO

 

PERSONAL:
(answers to questions in this area are OPTIONAL)
Single Married Seperated Divorced
Number of minor children: Ages of children:
Your date of birth:
Spouse's date of birth:

 

Have you ever owned your own business/franchise? Yes No
If Yes, give details:

 

FINANCIAL INFORMATION:
Do you have the capability to invest approximately $70,000 plus working capital ? Yes No
 
Will you need financing for this franchise? Yes No
Do you plan on having a partner? Yes No
If so, will the partner be active? Yes No
Do you plan on having investors? Yes No
If so, to what extent?
(note that all partners and/or investors will be required to submit a completed copy of this form)
 

 

Geographical area of preference?
1. 2. 3.
Are you willing to relocate? Yes No
When would you want to start your new business?

 

How did you happen to become interested in Quik Internet?

 

As you consider your experiences and abilities, you feel that you can operate a successful business of this type because?

 

PLEASE READ:
It is understood that the purpose of this questionaire is for information only, and it is in no way binding upon either Quik International or the applicant. It is however understood that the applicant has supplied the information contained to the best of his/her knowledge and ability and that Quik International relies on that fact in assessing the qualifications and desirablility of the applicant. Applicant understands that further information may be needed to approve the applicant for the purchase of the franchise that Quik International offers. By executing this form, applicant authorizes Quik International to further verify any information herein (with the exception of any employers or other contacts clearly marked "DO NOT CONTACT" by applicant).

 



Quik International

NON-DISCLOSURE CONFIDENTIALITY AGREEMENT

 

This agreement is entered into as of the______ day of ______________ 1997, by and between Quik International (referred hereafter as "Quik") and _______________________________________________ (referenced hereafter as the "Confidant").

It is the intention of said parties to enter into a business relationship in the near future. In an effort to maintain open dialogue between the two parties, it is necessary for Quik to disclose certain trade secrets to Confidant. QUIK possess valuable business and technical information including, among other things, concepts, know-how, vendors, software and trade secrets relating to design, engineering, development, manufacturing, software development, use, marketing, and sales of equipment and methods for Internet Service Providers (ISP) and Franchising.

QUIK desires written assurance that information disclosed in confidence to Confidant will be maintained in confidence and not used against QUIK's interests. The term "Confidential Information" used below means all valuable business or technical information QUIK has that involves any of the matters referred to above, that the Confidant obtains directly or indirectly from QUIK, provided that such information is in writing or, if orally disclosed, is summarized in writing to Confidant within sixty (60) days of such oral disclosure. QUIK will disclose, or allow Confidant access to, Confidential Information only for the purposes of evaluating the possible acquisition of certain rights with respect to all or a portion of such Confidential Information and/or to manufacture and/or to market products incorporating the Confidential Information.

Confidant agrees, except as may be provided in any future written agreement that may be entered into between QUIK and Confidant, that Confidant shall:

(1) take all such precautions as may be reasonably necessary to prevent the disclosure to any third party of QUIK's Confidential Information;

(2) not use for Confidant's own benefit any of QUIK's Confidential Information; and

(3) to the extent Confidant has not already done so, require its employees, agents, firm and associates to be bound in the same manner.

The foregoing commitments on Confidant's part shall have no application to any information that shall have been known to Confidant (in documented form) prior to this disclosure by QUIK, or to any information that shall, other than by an act or omission on Confidant's part, be or become generally available to the general public by any public disclosure by the QUIK or other party who is not obligated to QUIK, or to any information that is disclosed by Confidant by a third party without violating an obligation to QUIK, or to any information that is independently developed by personnel of Confidant who did not have access to QUIK's information.

Subject to the foregoing, this agreement shall not serve (1) to grant or to convey the Confidant any right or license to use any Confidential Information or invention of QUIK, whether patentable or not; (2) to grant Confidant the right to disclose the same to any third party or to use or practice the same except as provided in this agreement; (3) to practice the invention of any patents or copy rights, relating to the Confidential Information; and (4) to place either party under any obligation to enter into any further agreement, except as in each parties judgment it shall seem advisable.

The term of this Agreement shall be three (3) years from its execution date and all restrictions and obligations cited herein shall expire after such termination. This agreement shall be governed and construed in accordance with the laws of the State of Nevada, United States of America.

Confidant:__________________ Owner: Quik International
By:__________________
By:__________________
Murray Mead
Title:__________________ Title:__________________
Date:__________________ Date:__________________

Quik International
INTERNATIONAL FRANCHISE TERRITORY RESERVATION APPLICATION

 

The undersigned hereby makes application to be considered as a possible franchise Owner of Quik International.

I,__________________________________wish to acquire an exclusive territory franchise to offer Quik Internet Services to the general public. I understand that the territory I am applying for will contain a population of approximately______________in the following area.________________________________________________________.

I understand that the franchise fee is $45,000 and that I will need to acquire the hardware and software necessary to operate an Internet site through Quik International at a cost of approximately $18,200 and have approximately $5-$6,000 in reserve as operating capital.

I understand and agree that my application and deposit in no way guarantees me of being accepted by Quik International as a qualified franchise owner. Quik International has the right, for any reason, to accept or reject my application as they see fit and make their final decision.

I hereby submit a $5,000 deposit to Quik International along with this Franchise Territory Application understanding that should my application for a franchise be rejected or should I decide not to proceed, Quik International shall, within ten(10) days from the date of rejection, return my entire deposit to me.

I request to be sent a formal business application and a Franchise Agreement.

AGREED AND ACCEPTED this ______day of________________199_ by:

Signature____________________________

Name_______________________________

Address_____________________________

City, State, Zip_______________________

Telephone____________________________

Fax_________________________________

Email address__________________________