Form 21-007a - Questionnaire 21-007 - Iowa Customer/dealer Page 4

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Page 4
11. While present in Iowa, have employees from this supplier:
Yes
No
How Often?
Received any payments from you?
___
___
______________________
Sold merchandise or products in their possession?
___
___
______________________
Replaced your merchandise or products with
merchandise or products in their possession?
___
___
______________________
Removed or destroyed any merchandise or
products, for any reason?
___
___
______________________
Verified the removal or destruction of any
merchandise or products, for any reason?
___
___
______________________
Arranged for the removal or destruction of any
merchandise or products, for any reason?
___
___
______________________
Picked up merchandise, products, or other
company property?
___
___
______________________
Inspected purchased merchandise or products
for damage, obsolescence or unfitness?
___
___
______________________
Delivered merchandise, products, or other
company property?
___
___
______________________
Please explain all yes responses, including describing the merchandise or products involved in the above
activities:
12. While present in Iowa, have employees from this supplier trained you or your employees in:
Yes
No
How Often?
Servicing products or merchandise?
___
___
______________________
Product examination and trouble shooting?
___
___
______________________
Please explain any yes responses:
21-007d (03/14/11)

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