User Conversion - Advantage Plus Program

Distributor's Information

Distributor Company Name*

Distributor Representative First and Last Name*

First Last

Distributor Representative Phone*

Distributor Representative Email*

End User's Information

End User Company Name*

End User Contact First and Last Name*

First Last

End User Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

End User Contact Phone

End User Contact Email*

Total Number of Reusable Respiratory Users*

Estimated Annual Spend for Cartridges / Filters*

Information About The Moldex Product(s) End User Converted To:

Mask (check all that are in use)

7000 Series Half Mask
7800 Series Silicone Half Mask
9000 Series Full Face Mask

Cartridges (check all that are in use)

7100 Organic Vapor
7200 Acid Gas
7300 Organic Vapor/Acid Gas
7400 Ammonia/Methylamine
7500 Formaldehyde
7600 Multi-Gas/Vapor Smart

Filters (check all that are in use)

8910 N95 Pre-Filter
8970 R95 Pre-Filter
7940 P100 Filter Disk
7950 P100 Filter Disk Plus Nuisance Organic Vapor/Acid Gas
7960 P100 Filter Disk Plus Nuisance Organic Vapor
7990 P100 Filter Cartridge

Pre-Assembled Combination Cartridge/Filters (check all that are in use)

7140 Organic Vapor/P100
7640 Multi-Gas/Vapor Smart/P100

Accessories (check all that are in use)

7999 Filter Disk Splash/Spark Protector
0098 9000 Series Spectacle Kit
9780 Reusable Respirator Storage Bag

Information About The Competitive Product(s) End User Converted From:

What type of mask(s) were in use (please include model numbers if possible)*

What type of cartridges and/or Filters were in use (please include model numbers if possible)*

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