Distributor Application Form

Question Title

* 1. Please type in your personal data

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

Abacus 5

Abacus 380

Abacus 3CT

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

P500

Pictus 700

Clinical Chemistry Reagents

Not interested in Clinical Chemitry products

Other (please specify)

Question Title

* 4. Products of interest - Immunoassay

KleeYa

Gemini

Gemini Combo

Not interested in Immunoassay products

Other (please specify)

Question Title

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

Human 5-part

Human 3-part

Veterinary

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

200-400 tests/hour

400-600 tests/hour

600 or more tests/hour

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* 7. Service dept/ No of Engineers

1-5

6-10

11-20

more than 20

Other (please specify)

Question Title

* 8. Territory of distribution - Please list the countries

Europe

Asia-Pacific

Middle-East

Africa

Latin-America

North-America

Other than above

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

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* 10. Turnover in EUR /year

	<200.000 EUR	200-500.000 EUR	500-1.000.000 EUR	1-5.000.000 EUR	>5.000.000 EUR
2014	2014 <200.000 EUR	2014 200-500.000 EUR	2014 500-1.000.000 EUR	2014 1-5.000.000 EUR	2014 >5.000.000 EUR
2015	2015 <200.000 EUR	2015 200-500.000 EUR	2015 500-1.000.000 EUR	2015 1-5.000.000 EUR	2015 >5.000.000 EUR
2016	2016 <200.000 EUR	2016 200-500.000 EUR	2016 500-1.000.000 EUR	2016 1-5.000.000 EUR	2016 >5.000.000 EUR
2017	2017 <200.000 EUR	2017 200-500.000 EUR	2017 500-1.000.000 EUR	2017 1-5.000.000 EUR	2017 >5.000.000 EUR
2018	2018 <200.000 EUR	2018 200-500.000 EUR	2018 500-1.000.000 EUR	2018 1-5.000.000 EUR	2018 >5.000.000 EUR
2019	2019 <200.000 EUR	2019 200-500.000 EUR	2019 500-1.000.000 EUR	2019 1-5.000.000 EUR	2019 >5.000.000 EUR

Other (please specify)

Question Title

* 1. Please type in your personal data

Question Title

* 2. Products of interest - Hematology

Question Title

* 3. Products of interest - Clinical Chemistry

Question Title

* 4. Products of interest - Immunoassay

Question Title

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

Question Title

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

Question Title

* 7. Service dept/ No of Engineers

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* 8. Territory of distribution - Please list the countries

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

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* 10. Turnover in EUR /year

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* 11. Any further comments