Contact Person*: 
Company Name*: 
Address*: 
City / State / Zip*:  

Telephone Number*:    Fax: 
E-Mail*:   Year Established 
Web Site Address*:    

Ownership:  Individual   Partnership   Corporation    Subsidiary

Subsidiary of:

Key Product(s):  

Markets Served*: 

Primary Competition:

Major Distributors*:

Do you manufacture your own products?    Yes       No
Do you private label for distributors?          Yes       No

Are your products approved for sale in Canada? Yes       No     If Yes, License #

Total Number of Field Sales Personnel*:      Company Reps:      Manufacturer Reps:

Who directed you to NDC? 

What are your expectations from this program with our group?  Comments?

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This information is for NDC review only and is not a guarantee of an NDC contract. 
Thank you for your interest in NDC, Inc.