Distributorship Profile Form

1099 Distributorship Profile Form

Please complete the profile form below, and we will contact you to discuss distribution opportunities in your area.
Distributorship Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Principal Name*
Principal Email*
example@example.com
Principal Phone*

Area CodePhone Number
How many W2 Sales Reps are a part of your sales organization?*
How many 1099 Sales Reps are a part of your sales organization?*
Call Points: What surgeon specialties do you routinely call on?*
Description of Geography Covered*
Which Lines Do You Currently Carry?*
Do you carry any products that would be competitive (please list all):*
How Did You Hear About Us?*
Should be Empty:

1099 Distributorship Profile Form