BECOME A DISTRIBUTOR WOULD YOUR COMPANY LIKE TO BECOME AN EVAC+CHAIR DISTRIBUTOR Fill out the following form to be considered for a distributorship. PROSPECTIVE DISTRIBUTOR QUESTIONNAIRE • • • • • • • • Please complete this questionnaire as thoroughly as possible so full consideration can be given to your suitability. Name Company Name Email Telephone Address Line 1 Address Line 2 City STATE CHOOSE STATE (IF APPLICABLE)Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho IllinoisIndiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri MontanaNebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon PennsylvaniaRhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP CODE COUNTRY USACANADAMEXICO.........................................OTHER COMPANY URL # OF EMPLOYEES # OF SALES PEOPLE BRANCH OFFICES/WAREHOUSE LOCATION(S) WHAT REGION DO YOU CURRENTLY COVER? Would you be able to be a Stocking Distributor? YES NO Do you have Personnel to perform on-site Product Demonstrations? YES NO Would you be able to Conduct Training Sessions? YES NO Do you have the ability to Sell and Maintain Service Contracts? YES NO Would you appoint an Evac-Chair Specialist or Product Manager? YES NO SUBMIT DETAILS This document Does Not Constitute an Agreement with EVAC-CHAIR. MENU HOME EVACUATION CHAIRS EVACUATION SLEDS ACCESSORIES ABOUT US CONTACT US PRODUCTS EVAC+CHAIR 300H EVAC+CHAIR 500H EVAC+CHAIR 600H EVAC+CHAIR 700H EVAC+CHAIR POWER 800 CARRYLITE TRANSIT CHAIR EVACUATION CHAIR TRAINING EVACUATION CHAIR SERVICING EVACUATION CHAIR RENTAL ABOUT US WHY EVAC+CHAIR? OUR CUSTOMERS TESTIMONIALS NEWS E-BOOK DOWNLOADS FAQ's BECOME A DISTRIBUTOR ORDER FORM OTHER PRIVACY POLICY TERMS OF USE LEGISLATION FOLLOW US Facebook Twitter Linkedin