Xentura Medical Instruments

Distributor Profile Form

1. Company Information

Name:
Title:
Company Name:
Address:
Country:
Telephone:	Please include area/city code
Telefax:	Please include area/city code
E-mail address:
Website:
Date business started:
Number of employees:

2. Sales Organization & Geography

What related product lines do you currently carry:

Number of sales representatives in the organization:

Are these representatives direct employees? Yes No

Number of sales representatives who service the GI/Endoscopy field:

In what states/regions/countries do you currently distribute?

Which Xentura Medical products do you wish to distribute?

What do you expect your projected Xentura Medical product sales (US$) to be in:

Year 1:
$ Year 2:
$ Year 3:
$

What is your company's current annual sales volume?

Current annual sales volume for endoscopy instruments?

What is/are your company's competitive advantage(s)?

3. Government Registration

(For international applicants only):
Is government registration or certification required before Xentura products can be sold in your country:

Yes No

If yes, please briefly describe the requirements:

4. References

Name of company:

Contact name/title:

Phone Please include area/city code

Fax: Please include area/city code

Products:

Sales:

Name of company:

Contact name/title:

Phone Please include area/city code

Fax: Please include area/city code

Products:

Sales:

Name of company:

Contact name/title:

Phone Please include area/city code

Fax: Please include area/city code

Products:

Sales:

How did you hear about us?

Toll-free: 1.866.XENTURA (936-8872) • E-mail sales@xentura.com