COMPANY QUESTIONNAIRE
Please complete the entire application and submit any attachments along with the form. Country:
Date:
Full legal name of Organization : Initials of Organization (if desired): Name of Person Completing Application: Legal Address of Organization:
Address Line 1: Address Line 2: City: State: Postal Code: Phone Number:
Fax Number with Country Code: Primary E-mail Address (required):
Secondary Email Address (recommended): Website Address:
SECTION I: Organization Information
Establishment Date/Date Organized : Type of Organization :
Corporation Partnership
Association Member Organization
Sole Proprietorship University
Political Organization Government Agency Other: Enter Description
If Organization is a Government Agencies you MUST also complete this box. Organization is regulated by :
Local Government (State, Emirate, Province, Shire, County, City, Town, etc.) National Government (Country, Kingdom, Sultanate, Republic, etc.)
1. Purpose or Mission of Organization or applicable parent organization
2. Business Activities of Organization and applicable parent organization:
3. Other Relevant Information:
4. List Owners. If the organization is run by a Board of Directors or a Leadership Committee, please provide a list of the Officers. Organizational Chart: Submit with this application. Include all positions with names of the people occupying each
position. 1) Name: Title: Address: Telephone: Telefax: E-mail Address: 2) Name: Title: Address: Telephone: Telefax: E-mail Address:
5. Give the full name and job title of the person authorized to sign the agreement with the AHA.
6. Please identify and provide contact information for the individual(s) in your company responsible for sales, service and administration.
Sales: Service: Administration:
7. Is any high ranking government official or any relative of a high ranking government official directly or indirectly involved in the Organization? (For example, is the Organization under the patronage of a royal or ruling family member?) Yes No If Yes, provide name and title:.
8. Is the Organization a Subsidiary of a larger Organization? Yes No If Yes, provide the name and complete address of parent organization.
9. If Organization or parent organization has offices in any other location including any assets located in the United States, list all locations, otherwise check the box No other locations.
10. Is the Organization or parent organization affiliated or related in any way to any tobacco or pharmaceutical company or subsidiary? Yes No
If so please describe the relationship and disclose services provided for, and relationships with these companies/organizations or their subsidiaries or parents.
11. Are you currently a representative, dealer or distributor for another educational or healthcare company? Representative
Dealer Distributor
12. Describe the types of products and services sold, including brand names.:
13. Are you currently an agent or representative of any other company which manufacturers products similar to the Emergency Cardiovascular Care (ECC) product? Yes No
If “YES”, list companies:
a. Do you have any objection to us contacting the company listed above which manufactures products similar to the Emergency Cardiovascular Care (ECC) product? Yes No
SECTION II: Proposed Relationship
14. In your own words, please provide your understanding of the project.
15. Please describe below the nature of the business services or relationship that is proposed between the Company and AHA:
16. What is your geographic sales area for the ECC products? What country or countries will the ECC product be distributed?
17. What is the estimated print run/quantity for the life of the product? 18. Describe any promotional mechanisms/media:
19. Are there any specific branding requirements? Indicate whether it is proposed that any license of AHA’s copyrighted works or servicemarks will be extended to the Company (other than a limited license to use AHA servicemarks in connection with your marketing efforts).
20. Please also indicate whether any bulk sale arrangements are anticipated and, if so, provide details: .
21. Indicate the specific ECC materials to be distributed (please also specify the language or languages of such ECC materials),
22. Are there any requirements/restrictions/notices that must appear on material, i.e., notice of approval or certification, etc?
23. Do you have your own service facility/warehouse for stocking or contract with an outside service? Yes No Give the name and address of the warehouse.
1) Company: Address: Telephone: Telefax: Contact Person: Title:
24. If you do not have service facility/stocking warehouse, are you willing to establish one for support of products?
Yes No
If “YES”, when?
25. Will your Company use any consultants or third parties to fulfill the contractual terms with the American Heart Association? Yes No
If “YES”, please name the parties and describe their responsibility/role.
SECTION III: Financial Information
26. Projected sales for ECC products in units and by US dollars for next fiscal year: a. Target sales for the second year:
b. Projected sales increase per year:
27. Estimate the percentage of your total company sales that will be generated from the American Heart Association venture:
28. Your total Company sales for last year (in US dollars): 29. Your total Company sales for current year (in US dollars):
30. Your company’s paid in capital or owner’s equity (assets less liabilities on the balance sheet) 31. Bank name and complete address:
1) Name: Address: Contact Person: 2) Name: Address: Contact Person: 33. Insurance: What insurance do you currently have? Please attach a copy of your current policy.
Insurer : .
Policy Number: Limit of Liability:
a) What form of Business Insurance does your Company have? b) What does it cover?
1. Workers Compensation? Yes No 2. General Liability? Yes No
3. Theft? Yes No
4. Property Damage? Yes No c) What are the limitations of the coverage?
Non-Disclosure
Agreement
This Agreement is made between the American Heart Association, Inc. (hereinafter "AHA"), a New York not-for-profit corporation, having its principal offices at 7272 Greenville Avenue, Dallas, Texas 75231-4596, and Company:
Company:
Business Name/Address:
This Agreement sets out the parties' agreement regarding use and disclosure of Confidential Information.
1. "Confidential Information" means business affairs, finances, methods of operation, plans and/or other data proprietary to a party (the "Disclosing Party") and that is disclosed to the other party (the "Receiving Party") in writing and marked as "CONFIDENTIAL," or, if provided orally, is identified as confidential at the time of disclosure and then, is committed to writing, marked "CONFIDENTIAL" and delivered to the Receiving Party within three (3) business days of such disclosure. In no event shall the AHA be prohibited from disclosing funding or other resources provided to it by Company.
2. Except as otherwise directed by the Disclosing Party, Receiving Party, its agents and employees, will use the
same standard of care in protecting Disclosing Party's Confidential Information as it uses in protecting its own Confidential Information and will not disclose any Confidential Information of Disclosing Party to any third party, or permit any third party to examine and/or make copies of any Confidential Information.
3. The Receiving Party shall not be obligated to protect the confidentiality of information which 1) is generally known or available to the public, or which may later become generally known or available to the public, except where such entry is the result of an unauthorized disclosure by the Receiving Party, its agents or employees; 2) was in the lawful possession of Receiving Party without confidentiality restrictions prior to receipt of such information under this Agreement, or comes into the lawful possession of Receiving Party without confidentiality restrictions from a third party having a lawful right to disclose such information; 3) is independently generated by Receiving Party and not derived from the information supplied by the Disclosing Party; 4) is disclosed by Disclosing Party to a third party without a similar restriction; or 5) is required or requested to be produced by Receiving Party, its agents or employees, by law, regulation, court order, subpoena or other legal process.
4. Company acknowledges that the AHA may currently or in the future be developing information internally or receiving information from third parties that may be similar to Company's Confidential Information. Nothing in this Agreement shall be construed as a representation or inference that the AHA will not develop or review products, services or plans for itself of others that may compete with or be similar to products, services or plans contemplated by Company's Confidential Information.
5. The term of this Agreement is one (1) year from the date of execution, or until execution of a subsequent agreement between the parties, whichever is shorter. Provided however, that the obligation not to disclose any individual item of Confidential Information received by Receiving Party during the term of this Agreement shall continue for a period of two (2) years from the date of receipt.
6. Although the parties have executed this Agreement as a part of their discussions or negotiations regarding a potential transaction between them, neither party shall be obligated to enter into any other agreement with the other party.
7. The terms of this Agreement shall be construed in accordance with the laws of the state of Texas without regard to its conflict of laws provisions.
8. The Disclosing Party's exclusive remedy in the event of an unauthorized disclosure by the Receiving Party is an injunction against the Receiving Party to prevent further disclosure. In no event shall the Receiving Party be liable for any monetary consequences or damages, whether foreseen or unforeseen, as a result of the unauthorized disclosure.
9. This Agreement represents the entire understanding and agreement between the parties with respect to non-disclosure of Confidential Information and supersedes any prior or contemporaneous agreements, whether
oral or written, expressed or implied. Should any provision of this Agreement be held to be invalid, illegal or unenforceable, that provision shall be severed and the validity and enforceability of the remaining provisions shall not in any way be impaired or affected.
American Heart Association, Inc.
Company
By: By:
Title: Title:
Printed Name: Printed Name:
