BioStim® Provider Application
Fields marked with
*
are required
Your Name
*
Title
*
Company Name
*
Company Physical Address
*
Company Physical Address 2
*
City
*
State/Province
*
Zip Code/Postal Code
*
Country
Company Mailing Address
*
Company Mailing Address 2
City
*
State/Province
*
Zip Code/Postal Code
*
Country
Phone
*
Fax
Email
*
Website Address
How did you hear about BioStim?
Will you be the primary contact between BioStim and your company?
YES
NO
If no, please indicate: Name
Title
How long has the company been in business?
What type of business is the company?
Are you an owner or manager of the company?
YES
NO
How many employees does the company currently employ?
1-10
11-25
26-50
51-100
Over 100
How many service technicians does the company currently employ?
1-10
11-25
26-50
51-100
Over 100
Who in your company is authorized to sign a provider agreement?
What is the authorized signers title?
In what geographic area does the company provide service?
To which sector (s) do you plan on applying Biostim products? (please check the appropriate boxes)
Food Service
Municipal
Residential
Medical
How do you plan on marketing BioStim products?
Please list two customer references for the company.
Name of customer
How long
Name of customer
How long
By completing this application you give BioStim, LLC authorization to contact the references listed.
Additional Comments:
Thank you for providing the information requested. A BioStim representative will be contacting you.
