Distributor Questionnaire
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If you are interested in distributing Salivax™ products, we request that you fill-in the following information that would allow our sales executives to respond to your request in an intelligent manner.
 Please note: Although it is most unlikely that you will experience any problems responding to this form, certain non-standard browsers will not respond properly. If you experience any difficulties, (or if you are not using a forms-capable browser) you may email your response to this form to: postmaster@immunoscience.com.

Company Name:
Company Address 1:
Company Address 2:
City: State: Country:
Postal Code:
Contact Person:
e-mail Address:
Telephone Number:
FAX Number:
Years in Business:
Annual Sales in US$:
Prior Experience with Medical products? Yes No
Product/Manufacturer Reference:
Exclusive Territory Desired? Yes No
Specify Geographic Territory Desired:


Company Capable of Obtaining Local Government Approvals? Yes No
Bank Reference:
Estimated Volume (in Units) Year 1:
Estimated Volume (in Units) Year 2:
 


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