Distribution/Dealership	Joint Venture
New Technology Licensing	Associated Product Merchandising

Other business relationship, please explain:

2) What type of business or organization are you representing? (Check all that apply):

Automotive Business	Manufacturing Business
Potential Oilmedic Sponsor	Non-Profit Organization
Non-Military Government Agency	Individual Investor (accredited investors only)
Investment Banker	Professional Association
Foundation	Laboratory
Marketing

Other, please explain:

3) Please enter the following information:

Last Name:      First Name: 

Title: 

Company: 

Phone:     E-mail: 

Address: 

Apt.# / MailStop / Department: 

City:     State: 

Zip code:     Country: 

4) Special Comments:

Please provide enough additional information in the space below to allow us to understand more about you or your company. Include any other information that will help us get acquainted, such as company web sites, major customers, etc. It is helpful to let us know the best time of day to reach you by telephone.