Wholesaler & Distributor Application Form

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BSI is always looking for good Medical Representative Groups and Distributors who are interested in carrying the FLEXTEND® or COLDFLEX® product lines.

If you have an established company with a good sales record and are interested in selling any of the FLEXTEND® or COLDFLEX® products, please complete form listed below. We look forward to hearing from you!





 

First name

 
 

Last name

 
 

Your Title

 
 

Company Name

 
 

Street address

 
 

City

 
 

State/Province

 
 

Zip/Postal Code

 
 

Country

 
 

Phone

 
 

Fax

 
 

Company Website

 
 

E-mail (Required)

 
 

Questions and Comments