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:
Direct Employee
Commission Only
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:
Individual
Company
Additional Information
If you have any questions, or would like to add more details, please use the space below:
