Please complete all questions that apply:



Company name:                                                                                            Date:




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?



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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?







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Prospective Distributor/Representative Questionnaire




10.  Bank references:






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:
















Alfa Medical  59 Madison Ave, Hempstead, NY 11550 
eMail 1-800-748-1259 fax 516-489-9364