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Please fill in the form below. We will review the information you have sent in, and contact you about the possible steps to take next.
To read what this form is all about, click here.

 

 

Company Name:
 
Address:
 
Website:
 
Company Phone:
 
Company Fax:
 
       
Contact Person Position Email adress Mobile phone
       
Current / Past productlines Since Until Sales last FY in euros (optional)
Total sales:
       
Amount of sales people specialised in:
(please define target groups as listed below) * 		1998 1999 2000 2001 2002

* if sales people are not specialised by target groups, please specify the amount of sales time spend by target group

       
Target Groups for the Distributor and Time Spent per Target Group in %:

abdominal surgery

(%)  

vascular surgery

(%)

interventional radiology

(%)  

gynaecology

(%)

lung surgery

(%)  

urology

(%)

cardiology

(%)   heart surgery (%)
orthopaedic surgery/traumatology (%)   neurosurgery (%)
plastic surgery (%)   other, please specify :