Please complete all questions that apply:
Company
name: Date:
Address:
Telephone
Number: Fax
Number:
E-mail: Corporate
Website:
Contact: Title:
1a. Are you a corporation,
partnership or sole proprietorship?
b.
Length of time
in business?
c.
List active
company management:
Name: Title:
Name: Title:
d.
List active
sales management/sales representative personnel:
Name: Title:
Name: Title:
2a. Total number of
employees?
Page 2
Prospective Distributor/Representative Questionnaire
b.
Do you have multiple locations?
Please
list if applicable:
c.
Total outside sales staff? Inside:
3a. Do you have a
warehouse? Size:
b.
Do you have a showroom? Size:
c.
Describe products stocked for resale:
4.
List any products
that you presently sell which compete with Alfa Medical:
5a. Geographical
territory covered?
b.
Would you
accept any deviations from your established area?
6. What type of customers do you contact? (ie,
R&D, technical, medical, educational, etc.):
7a. Are you prepared to
respond to sales leads?
b.
Do you submit
sales follow-up forms?
c.
Do you prepare
monthly reports as far as sales, demand or stock?
8a. Do you have a direct
mail program?
b.
How many
prospects are on your mailing list?
9.
Do you have an
instrument service capability?
Page 3
Prospective Distributor/Representative Questionnaire
10. Bank references:
Name:
Contact:
Mailing
Address:
City State: Zip:
Telephone
Number:
Branch
Number:
Account
Number:
11. Federal ID Number:
12. Attach a minimum of 3 Business References.
13. Attach latest financial statement.
14.
Please include
any other information you feel is pertinent for our consideration of your
company:
Information
supplied by:
Signature:
Name:
Title:
Date:
eMail 1-800-748-1259
fax 516-489-9364