Membership in this association shall be composed of those firms, corporations, partnerships, or individuals operating for more than two (2) years, which perform the function of a specialized medical distributor who is primarily (over 50% gross volume) engaged in the sale and distribution of specialized medical supplies and equipment.

Please print out this form, fill it out and return with your dues check.  Thank you.

____________________________________________________________________________________________________

Firm Name                _______________________________________________________
Mailing Address         _______________________________________________________
City/State/Province    ___________________________________  Zip+4 ______________

Phone   __________________       Email Address   _______________________
Fax       __________________       Web Site            _______________________

DISTRIBUTORSHIP’S PRINCIPALS:

Date of First Sale to Customer ________________ (Founding date)    Years in Business: ________

Company is a:

Number of Outside Salespersons _______   Number of inside Employees _______  Total Number of Employees ______

What is your annual sales volume?

Principal Territory Covered (List states or provinces – whole or parts to be listed in the directory) _________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________

Branch Locations (List address in full and phone number)
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________

Major Business Thrust (specialties to be listed in the Directory)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

List all manufacturers for whom you distribute (*Asterisk those you warehouse) This information is held strictly confidential.)

(Attach a list if you have additional manufacturers) (over)

Please complete the following:

Do you as a distributor own any interest in a privately held company that manufactures products in the
health care industry?   Yes [ ]    No [ ]

If yes, give the company’s name __________________________________________________________
_____________________________________________________________________________________

Name of Firm’s Delegate to IMDA ______________________________Title________________________
Delegate’s Nickname for Badge ______________________

Spouse’s First Name _________________________   Nickname For Badge _______________________
Children’s First Names __________________________________________________________________
Delegate’s Industry Background (Biography) ___________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Delegate’s Special Talents (Musician, Computer Expert, etc.) _______________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Delegate’s Hobbies and Recreational Activities ________________________________________________
_______________________________________________________________________________________

How did you learn of IMDA?

PLEASE READ BEFORE SIGNING
I certify that the information in this application is correct and that our firm is primarily (over 50% of my gross volume) engaged as a distributor of medical supplies and equipment.:

Signature of firm’s Delegate: ______________________________________ Date: ________________

ANNUAL MEMBERSHIP DUES
Dues are to accompany your application, a proration of dues will appear on second year’s dues notice. Fiscal year is January 1 through December 31. IMDA Federal Tax ID number is 23-2267209.