Internet Retailer Free Subscription

	*Internet Retailer* is free to qualified professionals. Summary Description
	To apply for a FREE subscription to *Internet Retailer*, please answer ALL of the questions on the form below.
	The magazine publisher determines qualification and reserves the right to limit the number of free subscriptions.
	Geographic Eligibility: USA, Canada

1.	*Do you wish to receive a FREE subscription to Internet Retailer?*

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First Name:
Last Name:
Job Title:
Company:
	(Please provide your Company Name in full: abbreviations could disqualify you)
Street Address:
Suite/Floor:
City:
State:
Zip Code:
Country:
	(Note: If your country is not listed above, subscriptions are not currently available at your location.)
Phone:
Fax:
Email:
	(Note: Valid email address is required or you could be disqualified.)

What is the approximate number of employees in your company? (select only one)

Yes, please auto-fill my contact information for other publication qualification forms.

2.	Which category best describes your industry? (select only one)

Retail Chain or Store Consultant

Catalog/Direct Merchant Manufacturer

Internet Service Wholesaler/Distributor

Virtual Merchant/Web Retailer Other

University/School/Library

3.	If you answered Retail Chain or Store above, please specify what type: (select only one)

Department Store/General Merchandiser Food/Drug

Discount Homecenter/Hardware

Specialty Other

4.	Please indicate your primary job function: (select only one)

Interactive/Network Services Fulfillment/Inventory Management

MIS/Operations Financial Management

Database Services Executive

Marketing E-Commerce/E-Business

Merchandising Other

5.	Please indicate your title: (select only one)

Chairman/CEO/President/COO VP

EVP/SVP Director/Department Manager

CIO Other

CFO

6.	In lieu of a signature, we require a unique identifier to be used only to verify this subscription request. On what day of the month were you born?

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