New Product Request

New Product Requests must be approved by the Regional Sales Manager and Vice President before they are submitted to Engineering for final determination.

Sales Rep Responsible *

Sales Rep's Email Address *

Submitted By *

Email address of submitter for confirmation *

Sales Territory *

Regional Sales Manager *

Description of Product Requested *

Attach additional description, if needed, along with sketches, drawings, and detaield requirements if applicable.

File Upload

Customer Details

Facility Name *

City *

State *

Project Details

Estimated initial purchase quantity *

Estimated purchase quantity during
the first year (including initial purchase) *

List other Howard Medical products to be sold in conjunction with the requested new product. Include relationship between other products and the requested new product.
(For example: "New HI-Care carts are being purchasd. 85% of the carts will be configured with one of these requested new products.")

Associated Products

Percentage of related product sales dependent
upon our ability to supply the requested new product *

Has this customer purchased Howard Medical products in the past? *

Brief description of previous purchases including product type and quantities *

Will the requested new product replace sales of an item previously purchased by this customer? *

Brief description of product sales to be replaced *

Does the customer require a sample of the requested product before purchasing? *

Required delivery date for the sample