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StarSmilez Distribution Inquiry

We appreciate your interest in our products and services. Please tell us about yourself and your firm by completing and submitting this form.

For distribution inquires, please complete and submit this form. We appreciate your interest in our products and services

Territory, country, and/or region your company serves*
Your Name*
First Last
Your Position or Title*
Company Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How did you hear about us?*
How does StarSmilez fit into your product mix? List any complementary or competing items you carry. Tell us how we will create value together*
Year company established:*
Number of Employees*
Number of physical locations:*
Are their specific products in our product line that you are interested in?*
Which of the following markets does your company serve? (check all that apply)*
- Health products
- Children's toys
- Private practice dentistry
- Consumer sales
- Public health
- Dental profession educational market
- Institutional education market
In which of the following activities does your company perform? (check all that apply)*
- Wholesale
- Retail
- Import / Export
- Manufacturer
Do you use re-sellers or sub-distributors in your business?*
- Yes
- No
If Yes, how many?
Marketing Channels:*
- Direct mail
- Retail store locations
- Company website
- Industry tradeshows
- Online distributors
- Other
If Other, Please specify:
Have you previously purchased StarSmilez products? If so from whom.*
Who will serve initially as our primary contact person within your organization*
Phone number*
Email*
Your Website(s)*
Name
This field is for validation purposes and should be left unchanged.

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