Prospective Distributor Questionnaire

Please complete this questionnaire as thoroughly as possible so full consideration can be given to your suitability.

Company Profile:

Contact Name:* Address: Email Address:* Website Address:* Branch Offices/Warehouse Location(s)

Company Name:* Telephone Number:* Fax Number: Nº of Employees:* Required

Number of sales people:

Outside:

Inside:

What region/states do you presently cover?

Company Focus:

Please specify your Top 3 target industries or markets: 1) 2) 3)

Key Applications in that market:

Would you be able to be a stocking distributor? Yes No

Do you have the personnel to do 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

What technical qualifications do your sales people have?

List of existing companies and products represented:

Do you have your own distribution transport? Yes No Would you appoint an EVAC+CHAIR® specialist or product manager? Yes No

Why should EVAC+CHAIR® select you as a distributor? What would be your plans to advertise, exhibit, and/or promote the complete EVAC+CHAIR® product line ?

What Trade Shows do you currently participate in ? Please provide any additional information that you feel would be helpful in our consideration for your company:

This document does not constitute an agreement between the applicant and EVAC+CHAIR® North America LLC.

EVAC+CHAIR^® AND ITS SILHOUETTE SYMBOL ARE REGISTERED TRADEMARKS.

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