Dealer Questionnaire - USA

Name: (Required)

Company Name:

Company Address:

Company Address 2:

City:

State:

Zip Code:

Phone: (Required)

Fax:

Email Address: (Required)

Do you have a fixed store location? Yes No  Number of Locations:

What type of store? Outdoor Retailer Travel Goods Medical Supply Emergency Preparation Military Supply Specialty Other

Do you have a catalog? Yes No  Number Mailed:
How often Mailed:

Do you have a rep force? Yes No  How many:

Do you have a Web site? Yes No
http://

Are you an E-tailer only? Yes No  
What type of E-tail store? Outdoor Retailer Travel Goods Medical Supply Emergency Preparation Military Supply Specialty Other

How many units do you think you can sell per year?

Message:

All new accounts must agree to Hydro-Photon's Distribution Policy including provisions on Minimum Suggested Retail Pricing and Promotional Activity.