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. Email Website address Question Title * 2. Products of interest - Hematology 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 P500 Pictus 700 P780 Clinical Chemistry Reagents Not interested in Clinical Chemitry products Other (please specify) Question Title * 4. Products of interest - Immunoassay 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) Human 5-part Human 3-part Veterinary Question Title * 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 Question Title * 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 Question Title * 9. What other companies' products do you offer to the market? Question Title * 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 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 Other (please specify) Question Title * 11. Any further comments Question Title * 12. Where did you hear about Diatron? Done