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First Name*

Country:

Address Line 1*

Address Line 2

City*

Zip Code*

Primary Contact:*

E-mail*

Phone Number*

Fax*

Number of Years in Business:*

Annual Revenues:*

Number of Employees:*

Total Direct Sales Reps:

Number of Sub-Distributors:

Total Technical Representatives:

Product Interest :*

Hematology
Clinical Chemistry
ELISA/Immunology
Hemostasis/Coagulation
Electrolytes
Urinalysis
Microscopes
Centrifuges
Med-Surg
Surgical Instruments

Countries where you do business:

Territory of interest for HTI products:

Customer Support :

I. TECHNICAL SERVICE & SUPPORT

Total Application Support Staff:

Do you have a technical lab on site?

Total Service Engineers:

Do you offer on-site service?

Staff Experience Areas: Average Experience Level (1 = New to 5 = Expert)

Diagnostic Instrumentation

1
2
3
4
5

Reagent Applications

1
2
3
4
5

Application Troubleshooting

1
2
3
4
5

Computer Support

1
2
3
4
5

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