Distributor Information Form

Company/Organization*
First Name*
Last Name*
Address 1*
Address 2
City*
Province/State
Country*
Postal/Zip Code
Telephone #*
Fax #
Email Address*

Please provide the following information regarding your organization, and sales activity
1. Do you sell to customers only in your own country, or do you cover other countries also?

2. In what region of your country do you sell?

3. Name the other countries where you sell?

4. What are the products that you already sell.

5. Do you represent other chemical manufacturers. Please list the ones you represent.

6. Which laboratory chemical manufacturers are the main suppliers in your market?

7. How many years have you been in business?

8. How many sales representatives do you have on the road?

9. What is the size of your warehouse facility?

10. Please provide any other information that you feel would assist us in determining if a distribution agreement would be mutually beneficial.