Company Profile and Contacts
* Business Name
* Contact Name
* Address Line 1
  Address Line 2
* City
* State/Province
* Zip/Postal Code
  Country
*Telephone #
Fax #
*Email
Website Address
Primary Contact
Name
Title
Telephone
Email
Value of Partnership
Please give a brief description of what services your company provides.
Why is your company interested in creating a partnership with First Medical
Solutions? (Reseller, Referral Partner, Product Integration, IT Reference, etc.)
Who is your target market and customer base? What territories do you cover?
What will this partnership bring to First Medical Solutions?
IT Reference
If you have installed, supported or currently support a network and/or provided and installed hardware for a First Medical Solutions client and you wish to be a client reference, please fill out this section. If not, please skip to the next section.
Please provide us with 2 customer references of First Medical Solutions clients you have worked with.
 
(1)   Practice Name:
        Name of Lead Physician:
        Office Manager or
........Other Contact:
        Telephone:
        Email:
        When did you begin working ........with this client?
 
(2)   Practice Name:
        Name of Lead Physician:
        Office Manager or
........Other Contact:
        Telephone:
        Email:
        When did you begin working ........with this client?
 
General Company Information
Date Company Established:
Number of Sales Reps:
Total Number of Employees:
Revenue Last Year :
Revenue Current Year:
Your Top 3 Competitors: