Representative Profile Form

Please provide the following information:

I. Office Information:

Name
Title
Organization
Street address
Address (cont.)
City
State/Province
Zip Code
Country
Phone
FAX
E-mail
URL
# Years in Business
Other Office Locations?	Yes No
Branch Office
Branch Office
Branch Office

II. Key Personnel

III. Manufacturers (Represented in Order of Importance)

IV. Market Orientation

V. Sales Time:

VI. Competition (List in Order of Significance)

VII. Miscellaneous - Stocking, Buy/Resell

VIII. Territory (List in order of Importance) - Counties: