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     


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