Dealer Questionnaire - International

Company Name:

Company Contact (Required):

Position in Company:

Email Address (Required):

Company Address:

Company Address 2:

Company Address 3:

City:

State/Province/County:

Country:

Postal Code:

Telephone (Required):

Fax:

Website Address:

Type of business (please check all that apply):
Retail store. How many locations:
Internet/Online Store. Web site address:
Catalog. Number Mailed:  When do you mail them:
Discounter
Government Agencies
End users/consumers
Other. Please specify:
Other. Please specify:

Markets that you cover (please check all that apply):
Travel
Outdoor
Travel medicine
Pharmacy
Disaster Preparedness
Emergency first response
Other. Please specify:
Other. Please specify:

Product lines carried:

How many years in business?

How many customers do you have? Are they retail accounts? Yes No  
Do you sell directly to the end user? Yes No

What territory and/or countries do you cover?

Do you have a rep force? Yes No  Number of reps:

What is your company's annual revenue in local currency?

How would you market SteriPEN and to whom would you market it?

What are your top reasons for wanting to represent our products?

Do you have packaging requirements that we should be aware of? Yes No

If yes, what are the packaging requirements?

Are there import regulations that could cause difficulties for our product class?
Yes No

If yes, please tell us what the import regulations are.

Please provide two bank references: contact names, telephone numbers, and email addresses:

Please provide any further information that you would lke to tell us: