RETRAX Syringe Company History

RSS PURCHASE QUESTIONNAIRE.

Please fill the following information and we will answer you promptly.

The demand for the RSS-Point Guard, as well as the Retrax Safety Syringe, has exceeded all expectations. It is the policy of Retrax Safety Systems, Inc. to respond to each and every e-mail and fax we receive requesting information on our patented products.

However, before we can respond to any request we must obtain some basic information to help insure that the party requesting information about our medical products is properly licensed or authorized to obtain, use and/or distribute the medical devices Retrax Safety Systems manufacturers.

Please complete the attached questionnaire and return the same by pressing "submit".Upon receipt of your completed questionnaire we will be able to provide you with a price list and samples.

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Product(s) interested in: (Check One)	Point Guard Retractable Safety Syringe Both
Anticipated Monthly Quantiity:
Would you like Price Lists? (Check One)	Point Guard Retractable Safety Syringe Both
Do you have a Medical License authorizing the Purchase of Medical Syringes? (Check One)	Yes No
Provide Medical License Number Authorizing the Purchase of Medical Syringes:
Request A CD ROM:	Check to receive a free CD ROM Presentation.
Would you like us to send you information on the Company and its products in the future? (Check One)	Yes No

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