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Distributor Agreement Form


 
Company Name *
 
Email *
 
Confirm *
Postal Address
 
Street Address
 
Address Line 2
 
City
 
State / Province / Region
 
Postal / Zip Code
 
Country
 
Website
 
Phone Number *
 
Fax
 

PRINCIPAL CONTACT:

Details of Principal Contact
Name
 
Prefix
 
First
 
Last
 
Suffix
 
Job Title
 
Address
 
Street Address
 
Address Line 2
 
City
 
State / Province / Region
 
Postal / Zip Code
 
Country
 
Company Name
 
Phone Number
 
Mobile
 
Fax
 
Number of years with company
 

Trade References

PLEASE PROVIDE THREE TRADE REFERENCES:
(Contact name, organisation, post address, phone number, fax number and email address)
1
 
2
 
3
 

Bank Details

 
Bank Name:
 
Text
 
Bank full Address
 
Bank Contact Name
 
Bank Contact Phone number
 
Bank Contact email address
 
Bank sort Code
 
Bank Account Number
 

Distributor’s market information

 
Annual Turnover (mention currency)
 
How you would like to promote our products
 
How much sales do you expect to achieve in next quarter
 
Number of years in business
 
Number of years with present owner
 
Number of locations
 
List any other distributions you have in Medical Devices
 

Disclaimer

I certify that I am of legal age (the age of majority) for the country in which I reside. I have carefully read the terms and conditions of the distributors agreement. I also fully understand Global Linkx Policies and Procedures and agree to abide by all terms set forth in these documents. I hereby confirm that my signing of this application does not violate any other agreements or contracts to which I am a party.

After your application as a distributor has been accepted, you have a right to cancel this agreement with us. You must submit cancellation in writing to the principal office of Global Linkx within 7 working days from the date of signing this agreement. If you are not happy with our terms and conditions please don’t sign this agreement.
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