Mid-South Painting, Inc.

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Your Name Company Address City State Zip Phone Fax Email Address
1)	Square footage of the project you are considering:	0-10,000 10,001-25,000	25,001-75,000 75,001-150,000 Over 150,000
2)	New Concrete?	Existing concrete?	Eroded area?
3)	Excellent Condition	Fair Condition	Poor Condition
4)	Type of flooring interested in:	Sealer/Dustproofer Epoxy Flooring Clear Finish Polyurethane	Acrylic Colored (pigmented) Fiberglass Extreme Chemical Resistant
5)	Desired Thickness:	1/16" 1/8"	1/4" Unknown
6)	Specific brand name in mind?
7)	Additional information?
8)	Are Drawings Available?	Yes No