Summit Medical | Shippert Medical Technologies

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Distributor/Representative Inquiries

Summit Medical CE marked products are sold worldwide through a network of independent representatives and stocking distributors.  We invite inquiries from interested potential reps and distributors.  Please complete the following form to give us an overview of your business. 

Contact Information
Name:
Title:
Company:
Address:
Phone Number:
Fax Number:
E-mail:
Year Founded:

Website:
Type of business:
Corporation    Partnership    Sole Proprietorship    Other:

Key Personnel:
What territories do you cover?

What Summit Medical product lines are you interested in representing?
Ear, Nose & Throat
InstruSafe Products

Marketing and Sales Data

Which manufacturers do you currently have representation agreements?
Do you consider any of your current products to be competitive with ours? Which ones?
Whom do you consider to be your largest competitors?
 
Will you send personnel to Summit Medical for training? Yes

Financial Data

Federal Tax ID#:
Dunn & Bradstreet #:
State Reseller License #:
State:
Total Gross Annual Sales:

Accounting Contacts:
Purchasing Contact:
 
Phone:
E-mail:
 
Accounts Payable Contact:
 
Phone:
E-mail:


Credit References (Other Manufacturers):
Reference #1
Company Name:    
Company Address:
City: State: Postal Code: Country:
Phone: Fax:
Reference #2
Company Name:    
Company Address:
City: State: Postal Code: Country:
Phone: Fax:
Reference #3
Company Name:    
Company Address:
City: State: Postal Code: Country:
Phone: Fax:

Bank Reference:
Account #:   
Name of Bank:    
Address:
City: State: Postal Code: Country:
Phone: Fax:
 

Comments/Questions: