G.Care Distributor Information Form

G.Care Medical Co. Canada

Distributor Information Form

If you believe that your company should be the representative for G.Care Medical Co. in your country, please complete the attached Distributor Information Form and mail or fax it to us at +1 949-760-8060. Because of great, universal interest in our products, we respectfully request that you complete and return this form in exchange for pricing information and samples

Please print or type all information. This form must be fully completed. Attach additional sheets if needed. When completed, please send by fax to+1 (949) 760- 8060 send requested information to us via e-mail at gcaremedical@canada.com or gcaresupport@canada,com. Download the Distributor Form.

1.	COMPANY INFORMATION:
1.1	Full Company Name:	________________________________________________________
	Contact Person:	____________________________	Title:	____________________
	Street Address:	________________________________________________________
	Mailing Address:	________________________________________________________
	City:	____________________________	Country:	____________________
	Telephone No.	____________________________	Fax No.	____________________
	E-mail/Internet Address:	________________________________________________________
1.2	Form of Business (Corporation, Partnership, Sole Proprietorship, with date/year company founded):
	__________________________________________________________________________

BUSINESS OPERATIONS:

2.1

Your type of business:

Trading Company

Importer/Indenturer

Contractor Packaging Co.

Wholesaler/Distributor

Commission Agent

Retailer

Import/Export Broker

Manufacturer

2.2

No. of Employees:_______

No of sales persons: _____

Size of warehouse: _____

2.3

Your type of customers - list how many and in order of importance:

How many?	How many?	How many?
___ Wholesalers:	___ Chain Stores:	___ Hospitals/Health Clinics:
___ Distributors:	___ Department Stores:	___ Doctors' Offices:
___ Importers:	___ Independent Retailers:	___ End-Users:
Others, please specify_______________________

2.4

List the area/territories in which your company is active:_____________________________________

2.5

List all products or brands handled by your company:___________________________________________________________________________
___________________________________________________________________________________

3.	MARKETING/SALES:
3.1	Specify your estimated sales projections for our products:
	1st Year:	US$	_________	Units:	_________
	2nd Year:	US$	_________	Units:	_________
	3rd Year:	US$	_________	Units:	_________
3.2	Do you advertise the products you represent? Yes____ No____
3.3	Will you actively advertise and promote our product line? Yes____ No____
	If yes, please specify the media you recommend and the estimated annual cost:___________________________________ ___________________________________________________________________________________
3.4	What trade fairs/shows do you recommend for participation? Specify the locations, dates, approx. visitors attendance, and approx. space/booth costs:
	_________________________________________________________________________

REFERENCES:

4.1

Trade references:

List your 3 largest product line representations, preferably U.S. Companies:

Company Name/Address	Contact Person	Telephone and Fax Numbers
1.


2.


3.

4.2

Bank references:

Bank Name/Address	Contact Person	Telephone and Fax Numbers
1.


2.


5.	OPTIONAL - MARKET INFORMATION:
5.1	Statistical information:

Countries or Regions	Total Population	Birth Rate per 1,000	Total Number of Infants in Age Group 0-24 months

5.2

Competitive products information: Please list imported and locally made FEVER thermometers in these categories: fever indicating pacifiers, digital thermometers, and glass thermometers.

Brand Names	Product Name	Country of Origin or Manufacture	Average Consumer Selling Price in US$


6.	SPECIAL INFORMATION:
6.	Add, and/or attach, any other information you feel is appropriate which may assist G.Care Medical Co.in evaluating your company and to better understand any special market/marketing conditions as may be applicable to our type of products in your market(s). __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________


Form Completed By: Name: _________________________________________ Title: _______________________ Date: ______________ RETURN BY FAX TO: +1 (949) 760-8060