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Company Information
Principal's First Name:
Principal's Last Name:
Title:
Company:
Address:
City:
State:
select State
___________
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Arizona
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California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
Illinois
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South Carolina
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Texas
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___________
Alberta
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Manitoba
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Northwest Territories
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Nunavut
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Prince Edward Island
Saskatchewan
Quebec
Yukon
___________
Other-International
Zip Code:
Telephone:
Fax:
Web site:
Email Address:
Contact Information (If different from Principal Information)
Contact's First Name:
Contact's Last Name:
Contact's Email Address:
Company Information
For how many years has your company been established as a broker?
How many employees does your company have?
Products
What types of products do you represent? Please select all that apply.
Grocery
Meat
Bakery
Beverages
Prepared Foods
Dairy
Food Ingredients
Deli
Frozen
Produce
Confections
Other:
Services
What services do you offer your accounts? Please select all that apply.
Sales
Wholesale
Merchandising
Category Management
EDI
Distribution
Market Research
Planogram Development
Consulting
Warehousing
Marketing Plans
Other:
Businesses
To which of the following types of businesses do you currently sell?
Major Grocery Stores
Wholesalers
Club Stores
Independent Grocery Stores
Convenience Store
Food Service
Retail Food Distributors
Drug Stores
Mass Merchandisers
Food Service Distributors
Dollar Stores
Other:
To what areas/regions do you currently sell? Please list
Are you interested in developing sales for you clients in international markets for example, Canada or Mexico?
Yes
No
Do you participate with your clients at trade shows?
Yes
No
If yes, to what extent?
How do you charge for your services?
Commission
Retainers
$/Hourly Fee
Other Special Fees:
Can a Pennsylvania food company looking for a food broker contact you directly to discuss possible interest in representing them?
Yes
No
Would you like for someone from the Bureau of Market Development, Pennsylvania Department of Agriculture, to contact you to discuss their domestic and international marketing services?
Yes
No
Other
Select all of the Mythical beings in the following list
Tiger
Europe
Dragon
Zero
Nine
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