
| A. | Company Name | ______________________________________________________ |
|   | Address | ______________________________________________________ |
|   | City & Country | ______________________________________________________ |
|   | Phone # | _______________________________ |
|   | Fax # | _______________________________ |
|   | Name | Telephone | Fax |
| Inside Sales | _______________________ | ___________________ | __________________ |
| Outside Sales | _______________________ | ___________________ | __________________ |
| Shipping | _______________________ | ___________________ | __________________ |
| B. Do you define yourself as: | Broker | Yes |   | No |
|   | Agent | Yes |   | No |
|   | Retailer | Yes |   | No |
|   | Manufacturer | Yes |   | No |
|   | Other (explain) |   |   |