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 Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP CODE COUNTRY USA CANADA MEXICO ......................................... 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.