Higgins Supply Company, Inc.

Name:
Title:
Company:
Address (Line 1):
Address (Line 2):
City:	State/Province:
Country:	Zip:
Phone:	Fax:
Email:
Website:
Type of Company:	Manufacturer Retail Distributor Other:
Company Industry:	Garment Orthopedic Other:
Comments:
How should we contact you?	By Mail By Email By Phone

How did you hear about us?	Internet Search
	Advertisement Name of Publication:
	Trade Show Attendance Name of Trade Show:
	Business Colleague Name of Colleague:
	Other:

We are currently seeking international distributors of our products
and services. Please indicate your interest in the box provided.

Contact as Potential International Distributor

Yes, I would like to receive a copy of the Higgins Supply Company, Inc. catalog.
Yes, I would like to receive the following samples of Higgins Supply Company,
Inc. products:

All Orthopedic Products		All Garment Products
Aluminum Stays		Underwires
Fusion-Coated Stays		Spiral Boning
Standard Wrist Splints		Plastic Boning
Split Wrist Splints		White Boning
Spoon Wrist Splints		Other:
Universal Spoon Wrist Splints