Type
Of Enquiry
* Country
* Person Completing
form
Date Completed
Afghanistan Albania Algeria
American Samoa Andorra Angola
Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba
Australia Austria Azerbaidjan Bahamas Bahrain
Banglades Barbados Belarus
Belgium Belize Benin Bermuda Bolivia
Bosnia-Herzegovina Botswana Bouvet
Island Brazil British Indian O. Terr. Brunei Darussalam Bulgaria Burkina
Faso Burundi Buthan Cambodia
Cameroon Canada Cape
Verde Cayman Islands
Central African Rep.
Chad Chile
China Christmas Island Cocos (Keeling) Isl. Colombia Comoros
Congo Cook
Islands Costa Rica Croatia Cuba Cyprus Czech
Republic Czechoslovakia
Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt
El Salvador Equatorial Guinea Estonia Ethiopia
Falkland Isl.(Malvinas)
Faroe Islands Fiji Finland France France (European Ter.) French Southern Terr. Gabon Gambia Georgia Germany
Ghana Gibraltar Great Britain (UK) Greece Greenland
Grenada Guadeloupe (Fr.) Guam (US) Guatemala Guinea
Guinea Bissau Guyana Guyana
(Fr.) Haiti Heard & McDonald Isl.
Honduras Hong
Kong Hungary Iceland India
Indonesia Iran Iraq Ireland Israel
Italy Ivory
Coast Jamaica Japan Jordan Kazakstan Kenya
Kirgistan Kiribati Korea
(North) Korea (South)
Kuwait Laos
Latvia Lebanon Lesotho
Liberia Libya Liechtenstein Lithuania Luxembourg Macau
Macedonia Madagascar Malawi Malaysia
Maldives Mali Malta Marshall Islands Martinique (Fr.) Mauritania Mauritius Mexico
Micronesia Moldavia Monaco
Mongolia Montserrat Morocco Mozambique Myanmar Namibia
Nauru Nepal
Netherland Antilles Netherlands Neutral Zone New Caledonia (Fr.) New Zealand Nicaragua Niger
Nigeria Niue
Norfolk Island Northern Mariana Isl. Norway Oman Pakistan Palau
Panama Papua
New Paraguay Peru Philippines
Pitcairn Poland Polynesia
(Fr.) Portugal Puerto Rico (US) Qatar Reunion
(Fr.) Romania Russian Federation Rwanda Saint
Lucia Samoa San Marino Saudi Arabia Senegal Seychelles Sierra
Leone Singapore Slovak Republic Slovenia Solomon
Islands Somalia South Africa Soviet Union Spain Sri Lanka
St. Helena St. Pierre & Miquelon
St. Tome and Principe
St.Kitts Nevis Anguilla
St.Vincent &
Grenadines Sudan Suriname Svalbard & Jan Mayen Is
Swaziland Sweden Switzerland Syria Tadjikistan Taiwan Tanzania
Thailand Togo Tokelau Tonga Trinidad & Tobago Tunisia Turkey
Turkmenistan Turks & Caicos Islands
Tuvalu Uganda Ukraine
United Arab Emirates
United Kingdom United States Uruguay US
Minor outlying Isl. Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Virgin Islands (British)
Virgin Islands (US) Wallis & Futuna Islands
Western Sahara Yemen Yugoslavia
Zaire Zambia
Zimbabwe
Company information (please
provide the following)
* Company
Name:
Telephone
Address
1:
Town /
City:
State / Province:
* Email:
Country:
Postal code /
Zip:
Year your
company established:
Phone
No.:
Fax
No.:
Web
Site:
Key Personnel: Name
Title
Title if different
Managing
Director
Marketing Manager
Sales
Manager
Accounting/ Billing
Manager
Customer Service
Manager
Technical Service
Manager
* What geographical
territory(ies) do you sell in?
Do you have offices or
affiliates outside of your own country?
Yes
No
If yes,
please provide company names, city and country:
Do you sell direct to end
users?
yes
No
yes
No
Which end-user
markets do you address?
Hospital
Laboratory
Other
General Physician
Independent
Laboratories
Government
Institutions
R&D Institute
Number of outside
sales representatives:
Number of application
specialists:
Approximate annual
turnover:
What
companies do you currently represent ?
No
Company Name
Address
Products
1.
2.
3.
4.
5.
* Do you distribute
Chemicals?
No
yes
Company
*Do you distribute
Tips?
No
yes
Company
Do you pay
import taxes on:
Chemicals:
%
Tips: %
Comments:
Please list three International
Suppliers whose products you currently
distribute. Please give your bank account
information