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Q-Based Healthcare
Q-Based Healthcare
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Q-Based Healthcare Distributor Inquiry

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Please use this form to to supply the business details we need to qualify you as a distributor of our products. A marketing representative will get in contact with you as soon as possible to help integrate you into our distribution system. (Please note your information will kept in strictest confidence. If you do not wish to provide detailed information you should consider our affialite program.)

Company Name:  
Business Address:  
Business Telephone:  
Website:  
Email:  
Tax ID Number:  
Dunn & Bradstreet Number:  
Date incorporated or otherwise organized:  
Place of incorporation or organization  
Type of Business:  
     
Estimated Annual Sales:  
     
Describe your estimated purchase and resale monthly volume amounts (number of Qbased Healthcare units).  
Describe your current and projected marketing methods and how do you plan to market Qbased Healthcare products. Include a brief overview of the plan such as ambitions, goals and major plan components.  
What other types of products and brands do you sell?  
List locations at which you plan to sell Qbased Healthcare products  
     
Direct Contact Person:  
Email:  
Phone:  
Fax:  
Additional Comments:  
    Enter the code as it is shown:
   
This helps to prevent spamming.
     
   
   
Please press Submit only once

Hours of Operation: Monday - Friday 8 am -7 pm CST

Q-Based Healthcare
110 East Edward Street
Erath, LA  70533
Telephone:  337-937-8800

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