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Residential Building
 Information Request Form

If you own, operate, or manage a residential building, then we'd like to hear from you!

NOTE:  All inputs highlighted in RED are required fields for a successful submission.  We respect your privacy.  The information captured will be kept confidential and will be used soley for the purposes of evaluating your eligibility for unit.
 

First Name: *
Last Name: *
Title/Position: *
Company: *
Phone: *
Email: *
Name of Proposed Residential Location: *
Address of Proposed Residential Location:  
                 Street Address: *
                 City: *
                 State: *
                 Zip/Postal Code: *
Management Company Name: *
Property Type: *
Number of Floors: *
Total Units: *
Describe the proposed building(s) as completely as possible (demographics, other amenities, proposed common area for the machine, etc.):
Please state the reasons you think this would be a good location for a DVD rental machine:
 
 

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