Please note: All fields marked with an asterisk (*) are required.

	Your name *
	Your Position with this Firm *
	Company Name
	Company Address 1
	Company Address 2
	Company Address 3
	City
	State/Province		Postal Code
	Country
	Voice Phone Number * (include country code)
	Fax Phone Number * (include country code)
	Company email address *
	Company email address * (confirm)
	Your email address if different
	Company website

	Years company has been in the analytical, biochemical or general laboratory supply business *
	The number of direct employees of your company Less than five Five to ten Eleven to 20 More than 20
	Area that your company directly services customers
	Number of outside sales representatives
	Number of inside sales representatives
	Do you do “Direct Mail” programs?		Yes No
	How Often?
	When was the last time you did one?
	Was it successful?
	Do you produce your own literature?		Yes No
	Do you produce your own catalog?		Yes No
	How many pages?
	Is it in four color?		Yes No
	Do you produce any of your own products?		Yes No
	What are they?
	Do you pay your invoices with any major credit cards?		Yes No
	Do you accept credit cards payments from your customers?		Yes No

	Please list three sales or marketing references (other companies that you represent or distribute for).
	Reference Company 1
	Contact Name *
	Voice Phone *
	Fax Phone
	Email
	Reference Company 2
	Contact Name *
	Voice Phone *
	Fax Phone
	Email
	Reference Company 3
	Contact Name *
	Voice Phone *
	Fax Phone
	Email
	Which trade shows do you exhibit at?		Pittcon       Analytica Achema     HPLC HPCE         Other If other, please list:
	What trade shows do you attend?		Pittcon       Analytica Achema     HPLC HPCE         Other If other, please list:
	Following questions are optional:
	What would you like to see a supplier of yours do to make you more profitable?
	What do suppliers of yours do that is most disappointing to you?
	What is your annual sales turnover/volume?