Form 21-007a - Questionnaire 21-007 - Iowa Customer/dealer Page 3

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9. Have you purchased merchandise which was delivered from a location within Iowa?
Yes ____ No ____
How Often? __________________________________________________
If yes, please complete the following:
Name of Selling Point
Address of Selling Point
Month/Year
_____________________________
_______________________________________
___________
_____________________________
_______________________________________
___________
_____________________________
_______________________________________
___________
_____________________________
_______________________________________
___________
_____________________________
_______________________________________
___________
_____________________________
_______________________________________
___________
EMPLOYEE ACTIVITIES: The remaining questions involve activities of this supplier’s employees
while visiting you in Iowa. Where applicable, select yes or no. If no employees visit, go to question 17.
10. While present in Iowa, have employees from this supplier:
Yes
No
How Often
Installed products?
___
___
______________________
Assembled products?
___
___
______________________
Authorized the installation of products?
___
___
______________________
Supervised the installation of products?
___
___
______________________
Inspected products after installation?
___
___
______________________
Repaired products?
___
___
______________________
Authorized product repairs?
___
___
______________________
Supervised product repairs?
___
___
______________________
Inspected products after repair?
___
___
______________________
Become involved in warranty matters?
___
___
______________________
Please explain any yes responses. Include product descriptions and the dates any activities occurred:
21-007c (04/20/11)

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