Innovation Connection Technology Product Application

Revision 6.5 Innovation Connection Product Submission Form 1 of 3 CONFIDENTIAL

Innovation Connection Technology Product Application

Your product(s) are important to us. Please provide the following information

And all required collateral material with new product submissions.

Submit Completed Form to: Patterson Technology Center [email protected]

Company Name: Product Name: Address: City/State/Zip:

Phone: E-mail: Web Site:

Are we currently doing business with your Company? Yes No If Yes, please explain

Are any of your products sold by other Patterson Companies subsidiaries? Yes No If Yes, please identify which:

Which market/s is your product applicable?

Yes No Yes No

Yes No

Sample Marketing Brochures attached to this form Yes No

VENDOR INFORMATION

Contacts: (Name, Title)

Contacts: (Phone, Email Address)

Primary Business:

Phone: Email:

Primary Technical:

Phone: Email:

Primary Marketing:

Phone: Email:

Other Contact(s)

Phone: Email:

Dental Ortho Veterinary

Printed copies of this document are considered uncontrolled. 6595.1.Rev003 09.14.2016


How many years has the company been in business?

What marketing activities are planned for this product? (Ie: trade journal ads, distributor ads etc.)

How are you currently distributing your products? Dealer Direct Other:

Does company have field sales representation? Yes No If yes, what type of field sales representation: Dedicated Independent

How many customers do you have actively using your product?

Number of employees in the company?

PRODUCT INFORMATION Asterisk after number indicates field must be completed in order for product to be considered.

1*. Product name (include trademarks, etc):

2*. Product market Introduction Date: Product availability Date:

3*. Product description:

4*. What is the retail price of the product/service?

5*. Is there recurring revenue from this offering?

6*. What products, currently on the market compete with this product?

7*. How many customers do you have using your product?

8*. Does your company have a patent for this product?

9*. Is this product a medical device? Yes No If yes, must indicate or provide all that apply: 1) Product Medical Device Listing number: 2) Product 510K number: 3) Manufacturer Facility FDA Establishment Number:



4) CE marked: Yes No If yes, date applied: 5) FDA Approved? Yes No

Submitted by: Date: Phone/E-mail:

PATTERSON INTERNAL USE ONLY Product evaluated by: ___________________________________ Date: _________ Notes: ______________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Item approved to add by: _______________________________ Date __________


Innovation Connection Technology Product Application

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