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Toll Free: 866.632.2282
Phone: 615.366.3230
Fax: 615.366.3240
Customer Service Hours: Mon-Fri, 7:30 - 4:30 CST

CORPORATE OFFICE
BNA Corporate Center
402 BNA Drive, Suite 500
Nashville, TN 37217

WAREHOUSE
407 New Sanford Road
La Vergne, TN 37086

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Distributors
Manufacturers
GPOs
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Manufacturer Inquiry Form

Contact Person*

Contact Person Title*

Company Name*

Year Established

Telephone Number*

Email*

Address*

City/State/Zip*

Website Address*

Ownership

Individual Partnership Corporation Subsidiary

Subsidiary of

Total Annual Sales

Annual Sales in US/Canada

Key Product(s)

Markets Served*

Primary Competition*

List Primary Distributors*

Total Number of US Distributors*

% of Sales Through Distribution

% of Sales Direct to Healthcare Providers

Do you currently sell directly to self-distributing IDN’s? If so, which ones?

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

Total Number of Sales Personnel*

Company Reps

Manufacturer Reps

Is your organization interested in outsourcing its sales and/or marketing functions?

Yes No

Does your organization own its distribution facility(s) or do you outsource that function?

Own Outsource

Is your organization interested in outsourcing its distribution utilizing NDC 3PL Services?

Yes No

Do you have current contractual relationships with GPOs? If so, which ones?

Do you currently process rebates. If so, is that internally processed or do you outsource that function to a 3rd Party processor?

Is your organization interested in outsourcing its contracts & rebate processing?

Yes No

Who directed you to NDC?

What are your expectations in doing business with NDC?

Additional Comments

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Thank you for your interest in doing business with NDC. We appreciate your providing information about your company and will review and respond soon.

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NDC CORPORATE OFFICE

402 BNA DRIVE, SUITE 500
NASHVILLE, TENNESSEE 37217

PH —: 615.366.3230
FAX —: 615.366.3240