Contact Information:

Company Name:

Company Phone:

Ext.

WEB Address:

**Your Name:

Title:

**E-mail:

Primary Target:

Hospital

Other:

Physician Office

Specialty 1:

Specialty 2:

Specialty 3:

Medical Laboratory

Product(s)/Services you're interested in promoting through The Schwartz Group:

Current Marketing Vehicles:

Field Sales Force:

# of Reps: 

Accounts per Terr: 

Journal Ads:

Mailings:

Blast Faxes:

Product Shows:

Other:

Are your products/services sold:

Direct

Through Distributors
 /Wholesalers

Are your products services offered through:

National Contracts

Discounted to Purchasing Organizations

Schwartz Group Services interested in:

Schwartz Medical Account Profiling

Lead Generation/ Appointment Setting

Vacant Territory Coverage

Audience Generation for Medical Meetings – CME

Audience Generation for Medical Meetings – Promotional

Market Intelligence Gathering

Other

Additional comments/information/objectives: