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

Telephone

Address Line 1

Address Line 2

City

STATE

ZIP CODE

COUNTRY

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