Distributor and 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.

Name *

Title *

Email *

Company *

Address *

Phone *

Fax

Website

Company Type

Corporation
Partnership
Sole Proprietorship
Other

Dunn & Bradstreet

What territories do you cover?

What Summit Medical product lines are you interested in representing?

Ear, Nose & Throat
InstruSafe Product

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?

Areas of Specialty:

Provide a Brief Description of your Business:

Accounting Contact: *

Accounting Phone: *

Accounting Email *

Accounts Payable Contact *

Accounting Phone *

Accounting Email *

Credit References:

Credit Reference #1 - Company Name *

Credit Reference #1 - Address *

Credit Reference #1 - Phone *

Credit Reference #1 - Fax *

Credit Reference #2 - Company Name *

Credit Reference #2 - Address *

Credit Reference #2 - Phone *

Credit Reference #2 - Fax *

Credit Reference #3 - Company Name *

Credit Reference #3 - Address *

Credit Reference #3 - Phone *

Credit Reference #3 - Fax *

Bank Reference:

Bank Reference Account Number *

Name of Bank *

Bank Address *

Bank Phone *

Bank Fax *

Additional Comments

Phone