Lifespan Healthcare: DISTRIBUTOR INFORMATION FORM

Please tell us about yourself:

* indicates a required field

Your Name: *

Phone: *
office home cell

Company: *

Email: *

Address: *

City: *

State: *

Zip: *

Tell us about your business:

How long has your firm been in business?:

Current Yearly Sales:

Describe the territory covered by your company:

List 5 main medical facilities / accounts you
service within your territory:

Number of Sales Reps in your organization:

Do you have a showroom?:

Please describe your capability for providing
proposal / submittal drawings and documents:

Please name the companies whose products
you presently distribute:

List of products currently distributed:

Which areas in healthcare do you specialize?

Form of Distributorship: (check as many as apply)

	Critical Care		General Care
	Surgery

Ownership Structure:

Please list any areas of expertise
outside of healthcare?

How is customer service handled
within your organization?

Is your access to credit appropriate for
participating in projects that exceed $500,000?

Why do you believe Lifespan would
be a good match with your organization?

Please list some of your concerns and some
questions you'd like to discuss with us in a
follow-up conversation: