Hearing Aid Sweat Band : Distributor Form

Distributors If you are a Distributor of hearing related products and would like more information about adding the Hearing Aid Sweat Band™ to your product offering, please contact us by filling out the below information or calling us toll free at 866-644-2500.
			*Required Field
1.	Business Name:*
2.	Contact Name:*	First Name: Last Name:
3.	Address:*

4.	City:*
5.	State:*	Zip:*
6.	Phone:	( )- -
7.	Fax:	( )- -
8.	E-mail:*
9.	What percentage of sales are to: Dispensing Audiologists Hearing Aid Dealers End Users
10.	By what means do you sell / distribute your products? Catalog Internet Direct Sales Other: