Name:

Company:

Address:

City:

State & Zip:

Country:

Phone:

Fax:

E-mail:

Primary Contact:

Title:

Secondary Contact:

Title:

Which countries or geographical areas do you sell in:

Which companies do you represent? Please complete the table below:

Company

Main Product(s)

Annual Sales Dollar Volume

Company Reference & Phone #

How many full time sales representatives do you employ?

Do they have experience selling: Yes No

Impedance Cardiography Systems: Yes No

Pulmonary Artery Catheters: Yes No

New technology: Yes No

What markets do your sales representatives sell in?
(Please check all that apply)

Operating Room
Critical Care
Emergency Department
Cardiology Office

Other:

What requirements must be met in order to sell medical products in your sales area?

Bank Reference:

Completed by:

Date: