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Verizon is your gateway to better communications to your public. To see how Verizon can help your business with quality payphone products and services, please complete the questionnaire below. A Verizon Payphone consultant will contact you soon to discuss your Public Communications needs and opportunities. Name First MI Last Title Business name Address Street address City State Zip code Alabama California Connecticut Delaware District of Columbia Florida Hawaii Idaho Illinois ?Indiana Kentucky Maine Maryland Massachusetts Michigan Missouri Nevada New Hampshire New Jersey New York North Carolina Ohio Oregon Pennsylvania Rhode Island South Carolina Texas Vermont Virginia Washington West Virginia Wisconsin - Contact information E-mail Phone Ext. -- Fax -- Region Select... KY, MI, OH, PA, VA IL, IN, WI AL, FL, NC, SC AR, ID, MO, NM, OK, OR, TX, WA NV, N. California AZ, S. California Hawaii Other Type of market Select... Commercial Property Convenience Store Correction Facility Education Institution Entertainment (Amusement Park, Bowling Alley, etc) Government, Municipality Grocery Store Healthcare Hospital Housing Authority Hospitality Lodging/Hotel/Motel Public Highway or Sidewalk Resort Restaurant/Food Service Retail/Shopping Center Service Station Theater/Arena Transportation Service Other Are you interested in other Verizon services? Please choose Yes No If yes, what services are you interested in? Please enter Comments / questions How would you like to be contacted? Please choose No response required E-mail Telephone Fax Mail

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