Cnoga Distributor Form

Distributor Form

Dear potential distributor,
In order to become a CNOGA medical partner, distributing new line of non invasive medical devices incorporating NIBG (Non invasive blood glucose monitoring) we kindly ask you to fill the following form:

All information shall be kept confidential and will not be passed to a 3rd party.

Red fields are mandatory

General Details

Company name

Address

City

State/province

Zip/postal code

Country

Website

Ownership:

Public

Private

Contact Details

Prefix

Name

Department

Title

E-mail

Telephone

Fax number

Company�s Detailed Information

Regions in which the company is dominant

Main products on the company’s distribution portfolio

Glucometers
Oximeters
Sphygmomanometers
Other

Regions in which the company is NOT dominant but would like to become dominant in

Medical device distribution in which the company does NOT specialize but would like to specialize in

Glucometers
Oximeters
Sphygmomanometers
Other

Sale specification

Online
Catalogs
Pharmacies and other retail channels
Hospitals
Reimbursement / healthcare services
Other

Volume for each of major products (number of products sold during recent last three years.

	2005	2006	2007
Glucometers:
Oximeters:
Sphygmomanometers:
Other:
Other:
Other:
Other:

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