* 1. Please select the option below that best describes you:

* 2. Does the company have multiple locations?

If you answered "yes" to question #2, please either use the main office address or the location that you are most familiar with below, and we will contact the company directly to get the additional location addresses. Please note: our fully-functioning website will have the capability to list multiple locations at once, but we do no have that technology yet because the site is not built. Once we collect the additional location information, will be able to list this information upon launch of CareSpotlight.com.

* 3. Company Contact Information: (CareSpotlight.com serves only the CONTINENTAL U.S. Do not complete this survey if you are outside of the Continental U.S. Thank you.)

* 4. Please add the company website below:

* 5. Is the company a registered business in the Continental United States?

* 6. Please check the type(s) of care and/or services that this company currently provides:

* 7. What population(s) does this provider serve? Please check all that apply.

* 8. What age(s) does this provider serve? Please check all that apply.

* 9. The CareSpotlight Provider Directory has 3 levels and the basic (SILVER) level is FREE. We will also be running a special promotion for our GOLD level for the first 3 months post the official site launch. Please let us know what level interests you. Thank you!

* 10. How long have you been in business?

Thank you so much for completing this information! We are excited to build our Care & Service Provider Directory. This information will not be accessible until we officially launch our website. We will notify you when this occurs and look forward to working with you in the future!

* 11. Please let us know if you have any questions or concerns that we many contact you to discuss.