| Company : |
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| Website : |
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| First Name : |
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| Last Name : |
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| Position : |
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| E-mail Address : |
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Address :
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City :
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Country :
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Province / State :
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Zip / Postal Code :
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| Telephone : |
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| Safety Manager / Ergonomist (Facility) : |
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| -- Telephone : |
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| -- Email : |
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| Safety Manager / Ergonomist (Corporate) : |
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| -- Telephone : |
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| -- Email : |
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| Number of employees at your facility : |
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| How many facilities does your company have? : |
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| Is your company safety programs approved at a corporate or local level? : |
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| Do you use anti-fatigue matting? : |
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| -- If yes, wich type and brand do you use? : |
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| -- If yes, what is your annual matting budget? : |
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| -- If no, what are your reasons? : |
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| Do you have an anti-fatigue insole/orthotic program in place? : |
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| -- If yes, which brand? : |
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| -- If yes, what is your annual budget? : |
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| -- If no, why not? : |
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| Has your company ever conducted an evaluation program in regards to
floor matting, insoles/orthotics and worker comfort and fatigue ? : |
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| -- If yes, when and with what product? : |
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| What is the most important benefit from insoles/orthotics that you are most interested in achieving? : |
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Special Requests :
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