CUSTOMER RESPONSE FORM Customer Response Form We respect your privacy. Therefore, we will never sell, give, or otherwise provide your name, address, telephone number, or other information to anyone. Allow us to serve you by completing this form. Quality Asphalt Paving & Sealcoating, Inc. Michigan Division: 5990 M-99 North Homer, MI 49245 Phone: (517) 568-5884 Indiana Division: 57283 Nagy Dr Elkhart, IN 46517 Phone: (574) 522-6800 Toll Free: 800-748-2012 Fax: 517-568-5894 Office Hours: Monday - Friday 8 - 5 EST E-mail: sales@qualityasphalt.com Tom Sterett, Sales estimator, IN Dave Bowersox, Sr. sales estimator Matt VanEpps, Blue Prints Kent Tackett, President, Owner Patricia Tackett, Corp. Secr., Owner Al Dupuis, Sales Elkhart, IN Byron Welch, Sales, Michigan First Name: Last Name: Company Name: Title: E-mail address: Street address: City: State: Zip code: Phone (incl. area code): Fax: Alternate Phone: Best time to call: How did you find us? (check all that apply) Television Radio Newspaper Yellow Pages Referral Bill Board Search Engine Sign on our truck Other: My project is: (check all that apply) New Addition Repair Other: I am a: (check all that apply) Home Owner Architect Contractor Government Nonprofit Commercial Institutional Manufacturer Advertiser Other: I need more information about: (check all that apply) Paving Sealcoating Patching Crack Repair Striping Excavation Residential Driveway Commercial Lot Municipal Lot Other: Estimated Project Start Date: (MM/DD/YYYY) Any Additional Comments or Questions? Enter the code shown: