All Medical Billing, Inc

All Medical Billing, Inc.
Network Partnership Program
Partner Application

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All Medical Billing, Inc.
16291 NW 57 Ave
Miami, Florida 33014
Telephone (305) 949-0970
Facsimile (305) 621-1030

Demographic Data

Company Name:________________________________________________________________________________

Address:______________________________________________________________________________________

City:___________________________ St:_______ Zip:_________ Phone: (______)_____________Fax:___________

Fed. Tax I.D.#:_______________________________ State License:________________________________________

Type of business: Sole Proprietorship______ Partnership______ Sub S Corporation_______ C Corporation___________

If a corporation, name State of Incorporation:___________________________________________________________

If a corporation list name and address of registered agent:__________________________________________________

Name of principals / owners and their titles:_____________________________________________________________

______________________________________________________________________________________________

Financial Data

Name, address and phone numbers of 3 trade references:

Name Address Phone

____________________________________ ______________________________________ (______)___________

How many years has the company been in business?_________ How many employees does the company have?_______

What was/is your total gross sales for: ‘94________ ‘95_________ ‘96__________ ‘97_________ Est: '98___________

Business Activity Data

Please give a brief description of your current products and services, industries of focus and marketing activities.

_____________________________________________________________________________________________

What percentage of your gross sales do the following segments contribute: Please include descriptions of each

Computer Hardware: Sales______% Training ______% Service/Support______% Consulting______%

Computer Software: Sales______% Training ______% Service/Support______% Consulting______%

Please describe the type of hardware and software sold, training and support services provided, etc.

Type of Hardware sold (include brands, if you handle networks, etc.)____________________________________

________________________________________________________________________________________

Hardware Training (describe)__________________________________________________________________

Hardware Service/Support (describe)____________________________________________________________

Software: Resell_________________________________ Proprietary Software___________________________

Software Training (describe type)_______________________________________________________________

Software Service/Support (describe)_____________________________________________________________

Please list the type of system configurations your company has expertise with: _____________________________

_________________________________________________________________________________________

Please list your key competitors, with a brief description of each:

_________________________________________________________________________________________

What differentiates your products from competitors?

_________________________________________________________________________________________

Please list 3 customer references:

Name Address Phone

_________________________________ ________________________________ (_____)_________________

Please list current partnerships with other companies and nature of relationship:

_________________________________________________________________________________________

_________________________________________________________________________________________

Qualifications & Responsibilities

Please list the qualifications of the persons/persons responsible for the Partnership Program with All Medical Billing. Include any educational training or professional experience in the healthcare technology industry.

__________________________________________________________________________________________

If you do not have hardware experience, who will handle the installations, maintenance of the systems?____________

__________________________________________________________________________________________

What type of training do you provide?_____________________________________________________________

__________________________________________________________________________________________

How do you intend to provide training: Software?____________________________________________________

Hardware?__________________________________________________________________________________

How do you intend to handle support: Software?_____________________________________________________

Hardware?__________________________________________________________________________________

Describe the resources you will commit and an outline of your business plan for your growth as a All Medical Billing Network Partner:

__________________________________________________________________________________________

BY:___________________________________ Title:___________________________ Date:_________________