Distributor Opportunities

Distribution Opportunities

Use the form below to request a new account. You will be contacted when administrators approve your request.

Title *

* Indicates required field

Name *

First

Last

Company *

Address *

City *

State *

Zip/Postal Code *

Country *

Phone *

Fax *

Email *

Website *

Describe your company ownership/structure. *

What territory does your distributorship currently cover? *

Do you currently sell to spine surgeons? *

If yes, approximately for how many years have you sold to spine surgeons? *

If yes, how many spine surgeons do you actively sell to at this time? *

How many hospitals do you sell to at this time? *

What is your current hospital/end-user pricing in the sectors below for the primary spine implant categories (e.g. pedicle screws, MIS screws, MIS screws with integrated extended tabs, cervical cages, etc.?)
Enter "N/A" if not applicable.

Government/Public Hospitals and Tenders *

Teaching Hospitals *

Private *

Please list other spine products you currently represent and duration represented. *

What was your sales volume for the last calendar year?
Enter "N/A" if not applicable.

Government/Public Hospitals and Tenders *

Teaching Hospitals *

Private *

Please provide the following information for your company.
Enter "N/A" if not applicable.

Commercial Registration *

MOH Registration *

Import License *

What requirements would there be for SpineCraft to register our products in your market? *

Distribution Opportunities

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