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Company Name*    
Contact Name*    
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State*    
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Phone*    
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Web Site Address    
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Please list the products that
you currently represent
   
Are any of these products an EHR program?   Yes No  
If so, please list the EHR programs    
Have you offered EHR programs in the past?*   Yes No  
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Are you currently a VAR for another company?*   Yes No  
If so, which company/companies?    
How long have you been in the medical records field?   Years
How long have you been in the medical accounting field?   Years
How many employees do you have in your company?*   Total
    Sales
    Technical
    Administration
How many current clients do you have?    
What are your anticpated sales of GeniusDoc Software for the first year? (Existing Clients)    
What are your anticpated sales of GeniusDoc Software for the first year? (New Clients)    
What is the typical practice size of your existing client base?   (Number of Physicians)
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