New Distributor Application

Interventional Spine Inc. is actively looking for additional distributors, worldwide. Please complete the form below to help us get a better understanding of your distributorship and the geography in which you seek to represent Interventional Spine and our products. Thank you for your interest and we look forward to speaking with you soon.

*Indicates a required field
*Distributorship Name:
*Mailing Address:
*City:
*State/Province:
*Zip Postal Code:
*Country:
Website:

Do you currently sell to Spine Surgeons:	Yes No
If Yes, Approximately for how many years have you called on the Spine Market:	Select one 1-2 years 2-4 years Over 4 years
How many Spine Surgeons do you actively sell to currently?
How many active sales representatives does your distributorship employ?

What geography does your distributorship currently cover?

Please list which other Spine products you currently represent:

Company Contact Information
*First Name:
*Last Name:
*Phone:
*E-mail: