DISTRIBUTOR FORM

Please provide: Company Name: Street Address: City/State/Province: Postal Code: Country: Company Website: Telephone Number:
Please provide: Title: Direct phone number: E-mail Address: Enquiry email address:
Please indicate below, your type of business, are you a:
Please select all sales tactics you deploy in your territories:
1) How do you promote your product lines in general?
What customer segments do you serve?
What products are most interesting/relevant for your market?
Please provide: Business Name: Address: Contact Name: Contact Telephone:
Please provide: Name: Title: Address (if different from your sales address) Telephone: Email Address:
Please provide: Name: Address: Person to Contact: Telephone: Fax: Email Address: Account number:

Thank you.

Life Science Group aim to build long term relationships with our distributors so all information you provide is extremely useful.  The team will now review your details and contact you during our next quarterly onboarding cycle at the latest.