Distributor Application Form

Question Title

1. Please type in your personal data (Required.)

Title (Mr, Mrs, Ms, Dr)

First name

Last name

Company name

Position

Company address - Street, nr

City

Zip code

Country

Telephone Nr.

Fax Nr.

Website address

Question Title

2. Products of interest - Hematology (Required.)

Abacus 5

Abacus 380

Aquarius 3

Abacus Junior 30

Diatron Aquila

Abacus Vet5

Hematology Reagents

Hematology Blood control

Not interested in hematology products

Other (please specify)

Question Title

3. Products of interest - Clinical Chemistry (Required.)

P500

Pictus 700

P780

Clinical Chemistry Reagents

Not interested in Clinical Chemitry products

Other (please specify)

Question Title

4. Products of interest - Immunoassay (Required.)

KleeYa

Gemini

Not interested in Immunoassay products

Other (please specify)

Question Title

5. What is the hematology market volume in your country? (Placement per year) (Required.)

Human 5-part

Human 3-part

Veterinary

Question Title

6. What is the clinical chemistry market volume in your country? (Placement per year) (Required.)

200-400 tests/hour

400-600 tests/hour

600 or more tests/hour

Question Title

7. Service dept/ No of Engineers (Required.)

1-5

6-10

11-20

more than 20

Other (please specify)

Question Title

8. Territory of distribution - Please list the countries (Required.)

Europe

Asia-Pacific

Middle-East

Africa

Latin-America

North-America

Other than above

Question Title

9. What other companies' products do you offer to the market? (Required.)

Question Title

10. Turnover in EUR /year (Required.)

	<200.000 EUR	200-500.000 EUR	500-1.000.000 EUR	1-5.000.000 EUR	>5.000.000 EUR
2020	2020 <200.000 EUR	2020 200-500.000 EUR	2020 500-1.000.000 EUR	2020 1-5.000.000 EUR	2020 >5.000.000 EUR
2021	2021 <200.000 EUR	2021 200-500.000 EUR	2021 500-1.000.000 EUR	2021 1-5.000.000 EUR	2021 >5.000.000 EUR
2022	2022 <200.000 EUR	2022 200-500.000 EUR	2022 500-1.000.000 EUR	2022 1-5.000.000 EUR	2022 >5.000.000 EUR
2023	2023 <200.000 EUR	2023 200-500.000 EUR	2023 500-1.000.000 EUR	2023 1-5.000.000 EUR	2023 >5.000.000 EUR
2024	2024 <200.000 EUR	2024 200-500.000 EUR	2024 500-1.000.000 EUR	2024 1-5.000.000 EUR	2024 >5.000.000 EUR

Distributor Application Form

Question Title

1. Please type in your personal data (Required.)

Question Title

2. Products of interest - Hematology (Required.)

Question Title

3. Products of interest - Clinical Chemistry (Required.)

Question Title

4. Products of interest - Immunoassay (Required.)

Question Title

5. What is the hematology market volume in your country? (Placement per year) (Required.)

Question Title

6. What is the clinical chemistry market volume in your country? (Placement per year) (Required.)

Question Title

7. Service dept/ No of Engineers (Required.)

Question Title

8. Territory of distribution - Please list the countries (Required.)

Question Title

9. What other companies' products do you offer to the market? (Required.)

Question Title

10. Turnover in EUR /year (Required.)

Question Title

11. Any further comments

Question Title

12. Where did you hear about Diatron? (Required.)

Question Title

* 1. Please type in your personal data (Required.)

Question Title

* 2. Products of interest - Hematology (Required.)

Question Title

* 3. Products of interest - Clinical Chemistry (Required.)

Question Title

* 4. Products of interest - Immunoassay (Required.)

Question Title

* 5. What is the hematology market volume in your country? (Placement per year) (Required.)

Question Title

* 6. What is the clinical chemistry market volume in your country? (Placement per year) (Required.)

Question Title

* 7. Service dept/ No of Engineers (Required.)

Question Title

* 8. Territory of distribution - Please list the countries (Required.)

Question Title

* 9. What other companies' products do you offer to the market? (Required.)

Question Title

* 10. Turnover in EUR /year (Required.)

Question Title

* 11. Any further comments

Question Title

* 12. Where did you hear about Diatron? (Required.)

1. Please type in your personal data (Required.)

2. Products of interest - Hematology (Required.)

3. Products of interest - Clinical Chemistry (Required.)

4. Products of interest - Immunoassay (Required.)

5. What is the hematology market volume in your country? (Placement per year) (Required.)

6. What is the clinical chemistry market volume in your country? (Placement per year) (Required.)

7. Service dept/ No of Engineers (Required.)

8. Territory of distribution - Please list the countries (Required.)

9. What other companies' products do you offer to the market? (Required.)

10. Turnover in EUR /year (Required.)

11. Any further comments

12. Where did you hear about Diatron? (Required.)