Name of your company

Name of contact person


Contact telephone number

Contact email

Contact website

How long has your company been in operation

What does your company do

How many staff work for your company

What products / brands your company represents
(or has represented) over the last five years
(indicate exclusivity/non exclusivity and territory):

Does your company provide after sales services ?

How many staff members are there in your sales team?

Which distribution / sales methods are used ?

Direct Selling

Why are you interested in representing our company ?

Are you interested in an Exclusive or Non-Exclusive Distribution Agreement ?

Will you commit to sales targets in the Distribution Agreement ?

Will you sign a confidentiality agreement ?

Do you require samples ?

Address and contact person for sample delivery :

Courier company, account number

Thank you for taking the time to fill this in