* 1. Account Type Business     Personal * 2. Name * 3. Company name * 4. Company mailing address Address City State Zip * 5. Email address (business) 6. Phone number (business) * 7. Approximate number of employees at your location * 8. What are your areas of interest? Emergency planning Emergency training & preparedness Emergency equipment & supplies First aid kit maintenance services Multi-site supply or training programs * 9. How did you hear of SafetyMax? Internet Promotional mailing Email promotion Friend/Associate Other   Please tell us about your company (optional) 10. Does your company have an emergency response team? Yes    No 11. What type of emergency training does your current program include? General Emergency Preparedness CPR First Aid Emergency Equipment AED (Defibrillator) Building Evacuation Home Emergency Preparedness None Other 12. How does your company currently replenish its first aid supplies? Maintained by outside vendor Maintained by employee Not currently maintained 13. If maintained by outside vendor, name of vendor 14. Name of decision maker (manager) for these services 15. Would you like a SafetyMax consultant to contact you?

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Sincerely,
The SafetyMax Team
(800) 585-8506
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