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DISTRIBUTOR APPLICATION
Domestic U.S. Product Sales
Please fax or e-mail this form to Netech Corporation at 631-531-0101 or sales@netech.org

 
Company Name* Main Address*
City * State*
Zip Code* Website
Parent Company    
 

Primary Contact Name* Telephone*
Contact Title Fax*
Mail Stop/Address
(if other than above)		 E-mail*
Today’s Date Primary
Contact

Signature

Please fill in the following as completely as possible:

How many years has your company been in business
0-2 Years     3-5 Years      5-10 Years      10+ Years
Total number of employees  
Total Size of Sales Staff  
Size of staff that will sell Netech products  
Business Type
Sole Proprietorship         
LLC or Partnership          
Corporation         
Other      
Ownership
Privately Owned    
Publicly Traded       
Stock Symbol (if publicly held)
    Your company’s primary business focus and description of products sold:
  
    Specify type of product offerings that are currently sold by your company to hospital biomedical engineering departments
  
Indicate past or present experience working with any of Netech’s competitors   

Specify Netech’s product categories which you intend to sell

Defibrillator Analyzers Sound Level Meter
Electrical Safety Analyzers SPO2 Simulator
Gas Flow Meters Tachometers
Laser Meters Thermometers
Light Meters Ultrasound Power Meters
NIBP Testers Simulators Multimeters
Pacemaker Analyzers Temperature Calibrators
Patient Simulators Service Kits
Pressure Meters Timers
Indicate the geographic sales territory where you intend to sell Netech’s products





















Specify your expected annual sales volume for Netech products

Initial year  
Year #2  
Year #3  
    Explain how you plan to market Netech’s products including sales and marketing resources to be committed and strategies for generating sales leads and closing sales
  
Explain whether you currently perform test equipment calibration services on other products  
    Include additional information that may be relevant towards Netech’s evaluation of your distributor application and acceptance
  

 






More BioMedical Test Instruments
Defibrillator Analyzers
Electrical Safety Analyzers
Force Gauges
Gas Flow Meters
Infusion Pump Analyzer
Laser Meters
Light Meters
Multimeters
NIBP Testers/Simulators
Pacemaker Analyzers
Patient Simulators
Pressure Meters
Service Kits
Sound Level Meter
Spo2 Simulator
Stroboscopes
Tachometers
Temperature Calibrators
Thermometers
Timers
Ultrasound Power Meters
Ventillator Testers


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