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ITAMED CO
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  ITA-MED Customer Information Profile
If you would like to become our Authorized Dealer, please complete and submit the application below and one of our representatives will get back to you within 72 hours


  Additional Information



Company Name:
Contact Name:
Title:
President / Owner:
Phone:
Fax:
Email:
Website:
Address:
City:
State:
Country:
Zip:
  Other Company Information
Years in Business: 1-5 5-10 Over 10
Number of Full Time Employees: 1-10 10-25 25-50 Over 50
Please specify Business type: Medical Supply Store/ HME or DME Dealer
Pharmacy
Doctors Office/ Clinic
Hospital/ Nursing Home
Maternity/ Women's Health or other Retail Stores
U.S. Distributor
International Distributor
Other

If Other ( Description )
Do you carry or work with similar products now? Yes No


If YES, please specify which products and provide us with brand names.
Graduated Compression Hosiery
Back and Abdominal Supports
Maternity & Women's Health Supports
Durable Medical Equipment
Other Medical Products

If Other ( Description )
Are you satisifed with your current supplier? Yes No
What would you like to change and improve?
Which ITA med products are you interested and would consider carrying? Graduated Compression Hosiery
Back and Abdominal Supports
Maternity & Women's Health Supports
Durable Medical Equipment
Other Medical Products

If Other ( Description )
What do we need to do to earn and keep your business?