2004 - 2005 Hausmann Catalog Request Form
Name
Company Name
Address
City
State
Zip
Phone
Fax
email address
Please select one of the following:
I am interested in purchasing Hausmann products.
I am interested in selling Hausmann products.
I am interested in selling products to Hausmann.
If you are interested in purchasing Hausmann products, which of the following best describes your workplace?
Hospital
Nursing Home
Physician's Office
Physical Therapy/Occupational Therapy Facility
Other
If “Other”, please specify: