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Learn how to receive complimentary samples. Limit one per household. Ask sales representative for details.

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Name:
Mailing Address:
City:
State or Province:
Zip or Postal Code:
Home Phone Number:
Cell Phone Number:
Email Address:
How many people do you shop for in your family? 2   3   4   5   6   7+
What do you spend on absolutely all of your groceries in any given week? under $50 $50-$100 $100-$150 $150-$200 over $200
Do you  Own  Rent your home?
Are you concerned about Salmonella, E-Coli, bacteria or the general quality and cleanliness of grocery store foods? Yes  No
Most Mid-Atlantic food stores have begun offering selections of healthier food items, such as free-range poultry, organic vegetables and All-Natural beef products. Do you feel this is a positive trend? Yes  No
Given rising energy costs, several unnecessary auto trips to the store each week could add up to a significant amount. Have you begun to factor those potential costs into your weekly budget? Yes  No
Do you view grocery shopping as time consuming or inconvenient? Yes  No
How did you hear about Heartland Home Foods? Home/Trade Show Referred By Existing Customer  Saw A Heartland Truck Internet Search Received Samples At My Door Received Heartland Foods Mailer  Took A Phone Survey Other
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