RHINOS' NATION - "Needs & Wants" Survey Form
Please fill out and submit this form to activate your Rhinos' Nation Full Annual Membership or our 4 Month (FREE GIFT) Membership.

For those that want our FREE GIFT Membership for 4 Months, please just fill out and submit this form.
"FREE GIFT" - Fill out and Submit Survey and Receive FREE GIFT
(As a Rhinos' Nation FREE Gift Member, for 4 months you will be able to SAVE While Shopping With Our Quality BLACK Owned Businesses Nationwide, but your name will not be placed into any of our Drawings and Giveaways)


Here is how it works:

To get you started on your HUGE SAVINGS, just fill out the form and submit it today! Just think of the things you may "NEED & WANT" for your personal use to Purchase and SAVE with your Rhinos' Nation Membership Discount!

One of our great benefits is that we will be using your personal shopping list below of things you "NEED & WANT" to recruit more Quality BLACK Owned Businesses on our TEAM to help you save money while shopping!

Please fill out the form below so that we, Rhinos' Nation, can best serve you!

We will follow up with you after we receive your completed form! If you have any questions on this matter please contact us as soon as possible. Check with us on our rules and guidelines.

* Your personal information from this form will not be given or sold to any third-party companies!

Please Do Not use All CAPS to fill out this form. Thank you.

Email address *
Name (First & Last) *
Your answer
City/State *
Your answer
Phone Number *
Your answer
Company Name (optional)
Your answer
Check all below, which you may need and want to purchase and SAVE while shopping:
Please list other purchases you may wish to make with Quality BLACK Owned Businesses, below. Please separate with commas.
Your answer
Gender *
Are you one of our or signing up to become a Rhinos' Nation "FREE GIFT" or "Full Annual" Member? *
Did anyone refer you to us? Let us know!
Your answer
Comments, Questions, & Additional Information
Your answer
If you have any questions on this matter please contact us!
Email: membership@rhinosnation.com
Phone: 901.491.7529
Rebuilding A BLACK Nation!
A copy of your responses will be emailed to the address you provided.
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