Distributor Information
Company Name:
Address:
Address 2:
City:
State:
Zip:
Country:
Phone:
International Phone:
Fax:
International Fax:
Email Address 1:
Email Address 2:
Website Address:
Year Established:
Total Sales Last Year:
Total Number of Employees Last Year:
Contacts
President:
Sales Manager:
Marketing:
Sales Support:
Purchasing:
Information Systems:
Accounts Payable:
Location
Current Territory:
Territory Requested:
Number of Hospitals in Coverage:
Number of Sales Representatives in Territory:
Sales Representative Type:
Product and Representative Information
Number Manufacturers Represented:
Distributor Type
(check all that apply):
 Stocking
 Non-Stocking
 Independent Rep
 Other Please Specify 
Product Sales Method
(check all that apply):
 Individual Sales Calls
 Reps in the O.R.
 Direct Mail
 Catalog
 Telemarketing
Direct Marketing Details 
Percentage of Stocking Arrangements:
Please list the top six manufacturers you currently represent in order of sales:
Manufacturer
Products/Services
Sales Annually
Areas of specialties you focus on (General, Gyn, Cardio, Neuro, Urology):
 % of sales
 % of sales
 % of sales
 % of sales
 % of sales
 % of sales
 % of sales
 % of sales
 % of sales
How do you communicate with clients?
Yes  No
Do you have a voice mail system?
 
Do all your salespeople have access to the Internet?
 
Do you have a company web page?
Address:
   
Do all your salespeople have e-mail?
 
Do you use e-mail to communicate with reps?
 
Email Account Type:
Additional Information
If you have any questions, or would like to add more details, please use the space below: