DISTRIBUTOR Questionnaire

It´s important you fill in the questionnaire in all its parts, otherwise your request cannot be taken into consideration



Company Name
Contact person
Address
Country
 Phone
Fax
E-mail
Web site

Where did you hear about SIARE?


Which SIARE products are you interested in representing?

ANAESTHESIA PRODUTC LINE INCLUDING
Anaesthesia machines and Ventilators

I.C.U. RESUSCITATION PRODUCT LINE INCLUDING
I.C.U. Ventilators
Portable Ventilators
Turbine Ventilators
Paediatric – Neonatal Ventilators

TECHNICAL UNITS PRODUCT LINE INCLUDING
Pendant Units
Bed-head Units
 MISCELLANEOUS
Monitoring systems
Surgical Aspirators
Humidifiers

PROJECTS
Turn key projects

In which countries would you like to market our products?Please check the box if you market in the entire country, or identify the area you operate in (i.e., north, south)



What is your knowledge level of the above indicated product lines?

good
average
scarse

Which companies do you currently represent?


References may be requested from:



COMPANY INFORMATION


Year your company was established
Vat number (Only for UE countries)
Managing Director(s)
 Number of employees
Number of salespeople
Number of technicians

Main activities of your company


Banking Data


MARKET DATA INFORMATION

Country / Area
N. of hospitals in the country
N. of beds

Please state our main competitors in this country:

Manufacturer


 Model


 Hospital price in EUR



Privacy policy
In accordance with the Italian Privacy Law Nr. 196/03, all your personal data and information will be entered into our database and strictly used and processed for our corporate business activities. In accordance with the Article 7 of the a.m. law, thirds may request to change or cancel their data from our database at any time by simply notifying mail@siare.it.