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Mandatory fields *

First Name*

Last Name*

Job Title

Business Name*

Business Email*

Current relationship with Sam's Club*

Select one ... Sam's Club supplier (items sold at Sam's Club) Not a current Sam's Club supplier (items not currently sold at Sam's Club) Agency representing Sam's Club supplier Agency 3P Vendor (e.g. AdTech, MarComm) Other

How quickly do you plan to activate?

Select one ... 0 - 90 days 3 - 6 months 6 - 12 months 12+ months N/A

Industry

Select one ... Consumer Goods Information Finance Insurance Professional Scientific and Technical Services Administrative Support & Remediation Services Educational Services Health Care & Social Assistance Arts Entertainment & Recreation Travel & Tourism Government Services Other

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