PATIENT ATTENTIVE CARE MEDICAL EQUIPMENT, INC.

3131 Riviera Drive, Suite 306, Sarasota, FL 34232-4739
Toll Free (877) 577-0001 ~~ Telephone (941) 379-0001 ~~ Cell (941) 321-2034
Fax (941) 923-9529 ~~ Email sales@patientmoving.com

 

DEALER CONTACT INFORMATION

Company: _________________________________________________________________
Principals’ Name: ____________________________________________________
Title: _____________________________________________________

Mailing Address: __________________________________________________________________
City: ___________________________________ State: _________________ Zip: ____________

Shipping Address: _________________________________________________________________
City: ___________________________________ State: _________________ Zip: ____________

Phone #: _______________________ Ext: ________ Email Address: _______________________

Fax #: __________________ Toll Free #: _________________ Cell Phone #: ________________

2nd Contact: ________________________________________ Title: _______________________

Phone #: _______________________ Ext: ________ Email Address: _______________________

3rd Contact: ________________________________________ Title: _______________________

Phone #: _______________________ Ext: ________ Email Address: _______________________

 

What geographical area does your company cover? Please include Zip Codes, Counties, or Other territorial landmarks or references:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

What Products and Services does your company offer? (Please check all that apply)

Adaptive Vehicles for Handicappe

Elevators

Wheelchair & Scooter Sales

Ceiling Lift Systems

Lift Chairs

Vehicle Lifts

Stair Lifts/Stair Glides

Automatic Door Openers

Home Modifications

Ramps

Wheelchair & Scooter Lifts

Porch Lifts

Hospital Beds

Other Products & Services not listed above:

________________________________________________________________________________

________________________________________________________________________________