TELL US ABOUT YOU!

Name:
E-mail Address(REQUIRED):
Address: 
City: 
State: Zip:
Phone; 
Best Time To Call:
Who Will Use This Chair Most Often? 

WHAT FEATURES ARE YOU LOOKING FOR 
IN YOUR NEW RECLINER?

Please indicate YOUR choices in the following categories...

1. Style of recliner:Wall Hugging Rocker Swivel Lift High Leg

2. Cover of recliner:Fabric Leather

3. Color of recliner:Brown Green Burgundy Tan Blue 
                       Other (Please Specify)

4. Options on recliner:Massage Cooler Phone Heat None

5. Price range of recliner:$300-$399$400-$499$500-$599$600-$699$700-$799$800-$899$900-$999Over $1000

6. Would you like more information on our delivery service?: YES  NO  

7. Would you like more information about our 12 months same as cash financing?: YES NO

8.Please Add Any Additional Comments Below: