AADCO MEDICAL

Head of Department Promotion Application

This application must be completed in its entirety, or it will not be considered.

Head of Department Promotion

Subject Candidate Information

Institution(Required)

Physician Name(Required)

Title(Required)

Department(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Business Purpose Statement

Describe this physician's Department Management responsibility:(Required)

Quantity dollar volume of sales generated from this department in the last 12 months:(Required)

Promotional Item Requested:(Required)

ErgoLite® Radiation Protection Apron

Other Apron (explain below)

Other Category (explain below)

If this is not a Head of Department request for an ErgoLite®, please clarify and qualify the item being requested.

Describe in detail how this decision maker will be able to positively influence sales?(Required)

What competitor(s) hold the largest share of business in this department?(Required)

List other departments in this institution who have purchased from AADCO in the past 12 months:

Forecast

Provide a sales forecast of anticipated business generated from this department by category over the next 12 months as a result of this promotion. If the application for promotion is approved, you will be required to report real sales against your forecast moving forward.

Aprons(Required)

Eyewear(Required)

Barriers & Shielding(Required)

X-Drapes(Required)

Syringes(Required)

Other(Required)

Other Contacts

Name of Department Manager(Required)

Department Manager Title(Required)

Phone(Required)

Name of Department Supervisor(Required)

Department Supervisor Title(Required)

Phone(Required)

Acknowledgement

Account Manager Name(Required)

First Last

Date(Required)

Head of Department Promotion Application