Name:

Company/Department:

Address 1:

Address 2:

City:

State/Province:

Country:

Zip/Postal Code:

Current Position / Type of Occupation (How Long) :

Home Telephone Number ( Best Time To Call):

Work Telephone Number ( Best Time To Call):

Fax:

Email:

Business Owner(s) Name:

Type of Business (Describe):

How Long In Business (years):

Number Of Sales People Representing Your Company:

Approximate Annual Sales Of Business:

Key Products Sold (specify brand names and type of products):

Type Of Business Location:

Office Home Other

Other (Describe):

How Long At This Address:
Own Rent Lease

How Sales Leads Are Generated:
Newspaper Radio Television Canvassing Home Shows Mall Shows Direct Mail Yellow Pages Referrals Other (Describe Below)

Other (Describe):

Current Financial Stability: (Excellent, Good, Fair):

When would you like to start your Eagle Distributing PHOENIX SYSTEM 2100:

How soon would you be willing to follow-up using our lead programs?:

Will you have a partner? (If yes, name):

How many PHOENIX SYSTEM 2100 residential fire detection systems do you expect to sell in your first full year in operation?

How did you arrive at this figure:

What would you consider to be your strongest trait?:

What would you consider to be your weakest trait?:

Our dealers have installed thousands of PHOENIX SYSTEM 2100 residential fire detection systems. Because of our Mission To Make America A More Fire Safe Place many lives have been saved.

How would you feel if you knew that you were part of a team responsible for educating people about the dangers of home fire and saving lives for a living?

Where would you like to locate your Eagle Distributing PHOENIX SYSTEM 2100 Dealership? (List your four preferences in order):

How did you learn about our PHOENIX SYSTEM 2100dealership opportunity? (specify):

When would you like to have a personal meeting?:
Within 1 Week Within 1 Month Within 2 Months Other

We thank you for your dealership inquiry and look forward to speaking with you soon.

If you have any Comments/Questions please let us know:

The confidential information you have provided is not a contract and thereby DOES NOT incur obligation by either party.