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Distribution 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:

C Corp LLC
S Corp LLP
Sole Proprietership Other
     
  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 Nexxspan 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: