Empire Health Care Solutions

Contact Information

*First Name       *Last Name  

*email:                          Title  Select ... Dr. Mr. Mrs. Miss Ms.                      

*Phone       ( )  -   ext  

Preferred Method of  Contact:    Phone     Email

Company Information

*Company/Organization 

*Address 1                   

*Address 2                   

*City                               *State:  AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VI VA WA WI WV WY   *Zip 

*Business Category     Select . . . Consultant - CPA Consultant - Clinical Consultant - Technology Consultant - Financial/Business Medical Supplies - Manufacturer Medical Supplies - Distributer Pharmaceuticals Insurance Employee Benefits Other Health Care Related Products Other Health Care Related Services Computer Technology - Hardware Computer Technology - Software Other Information Technology Other

*Business Type Corporation  Proprietor Partnership

Annual Revenue    Select <= $ 500,000 $ 500,000 <= $ 1,000,000 $ 1,000,001 <= $ 2,000,000 $ 2,000,001 <= $ 5,000,000 $ 5,00,001 <= $ 10,000,000 $ 10,000,001 <= $ 15,000,000 $ 15,000,001 <= $ 20,000,000 $ 20,000,001 <= $ 30,000,000 $ 30,000,001 <= $ 50,000,000 > $ 50,000,000           Employees  Select . . . <= 100 101 <= 200 201 <= 300 301 <= 400 Over 400

*Does your company have any current affiliate agreements?     yes no

              If yes, describe nature:

*Does your company have a corporate mission/philosophy? yes no

Does your company have a quality review or assurance program? yes no

*Describe your product or services

If you have brochures, descriptions or other marketing information related to your product and/or services you may attach up to 3 files in .doc, .txt, .pdf, .ppt or .xls

formats here ( Use the browse button to locate the files on your local computer):

*Agreement

I agree that all information provided and discussions are of a confidential nature and are only intended for the purpose of initiating a dialogue regarding the establishment of a potential business relationship with Empire Health Care Solutions.  Furthermore, I agree that all information of a proprietary nature and  will not be shared with or disclosed to any competitors of Empire Health Care Solutions or used for any other purposes other than exploring the potential relationship opportunities with Empire Health Care Solutions.

                                      I agree   I disagree

                                    Initials         (date mm/dd/yyyy)

You will receive a confirmation immediately regarding either the success of your submission or any errors that require correction prior to submission.