Distributor Application

Company Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

How did you find MAC Medical?(Required)

Are you competing against a current MAC Medical Rep or Distributor?(Required)

Yes

Do you intend to represent MAC Medical to the fullest ability as an alternate to your current supplier?(Required)

Yes

What is your sales area?(Required)

What is your companies’ main focus? Hospitals, ASC, Planner, Etc.?(Required)

What other manufacturers do you represent?(Required)

What is the annual sales volume?(Required)

How many reps are covering in your territories?(Required)

I certify that all information provided is true and correct.

Printed Name(Required)

Signature(Required)

Title(Required)

Date(Required)

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