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 Abacus 3CT 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 Clinical Chemistry Reagents Not interested in Clinical Chemitry products Other (please specify) Question Title * 4. Products of interest - Immunoassay KleeYa Gemini Gemini Combo 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 2014 2014 <200.000 EUR 2014 200-500.000 EUR 2014 500-1.000.000 EUR 2014 1-5.000.000 EUR 2014 >5.000.000 EUR 2015 2015 <200.000 EUR 2015 200-500.000 EUR 2015 500-1.000.000 EUR 2015 1-5.000.000 EUR 2015 >5.000.000 EUR 2016 2016 <200.000 EUR 2016 200-500.000 EUR 2016 500-1.000.000 EUR 2016 1-5.000.000 EUR 2016 >5.000.000 EUR 2017 2017 <200.000 EUR 2017 200-500.000 EUR 2017 500-1.000.000 EUR 2017 1-5.000.000 EUR 2017 >5.000.000 EUR 2018 2018 <200.000 EUR 2018 200-500.000 EUR 2018 500-1.000.000 EUR 2018 1-5.000.000 EUR 2018 >5.000.000 EUR 2019 2019 <200.000 EUR 2019 200-500.000 EUR 2019 500-1.000.000 EUR 2019 1-5.000.000 EUR 2019 >5.000.000 EUR Other (please specify) Question Title * 11. Any further comments Done