Circadiance New Account Questionnaire

By filling out this form you are requesting to open an account with Circadiance and order products through the company you are listing below. Please allow up to 5 business days for this request to be processed.

Please note this form is NOT for individual patient use.

Official Company Name*

Corporate Headquarter's Address*

Ship To Address*

Billing Address*

Billing Contact Name*

Billing Contact Email*

Billing Phone Number*

Billing Fax Number

Company CEO Contact Name

Company CEO Email Address

Company CEO Phone Number

Company Website URL*

List all current product lines that your company sells*

How do you sell your products?*

Internet
Direct Sales
Distributor

Number of employees?*

Number of sales reps?*

How many locations do you have?*

How long has your company been in existence?*

What is your sales territory?*

Does your company also sell outside of your country?*

Estimate for annual sales volume for Circadiance product line that you are interested in representing?*

If international: briefly explain the product registration process for your country and the average length of time it takes to complete. If the product is FDA approved or CE marked, it may not require registration.

If International: are English instructions acceptable?

If international: what is the official language(s) of your country?

Comments

View terms of use and privacy policy online at https://circadiance.com/privacy-policy/

I have read and agree with the Circadiance terms of use and privacy policy.*

Thank you for interest in Circadiance Products!