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Reseller Info Form

*Notes required fields

Main Corporate Address
*Company Name:**
Street Address:
City:
State:
Zip:

Title:
*First Name:**
*Last Name:**
Phone Number:
*Your Email:**

States Represented:
Is a network established to reach seniors living independently in the various communities:	Yes No
Describe Briefly:	Please enter information about your senior network.
Do you have partnerships with home care agencies:	Yes No
Describe Briefly:	Please enter information about your partnerships with home care agencies here.
Do you have IT services capabilities:	Yes No
Do you have Sales and Marketing Personnel:	Yes No
Do you have experience in implementing senior technology:	Yes No

Estimated resident population (totals) at high risk for falls (on assessment)
Independent Living:
Assisted Living:
Skilled Nursing:
Subacute Rehabilitation:

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Did You Know?

"Falls are the leading fatal injury among elderly."

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