Distributor Questionnaire FormVIA Global Health2016-10-07T11:31:58+00:00 If you are a human and are seeing this field, please leave it blank. Distributor Questionnaire Your Name Job Title Company Email Company Contact Information Company Name Company Telephone Company Address Shipping Address (if different) Principal Officer or Owner Primary Sales Contact Describe your Company's Major Business Activities Do you have any local association memberships or affiliations? Marketing and Financial Information Describe the types of products currently represented, including brand names What geographic territories do you cover? How long have you been in the medical device business? Note below any government or private organizations with whom you have good current liaison Sales Volume Last Year (including currency) Do you have a VAT Clearance Certificate or Tax ID Technical Information Do you have your own service facility and workshop for repairs and overhaul of products? If no, do you contract with an outside service contractor? Is there any additional information you would like product suppliers to be aware of? Can you assist with product registration if necessary? By clicking "Submit" I agree to the VIA Global Health User Agreement.