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Distributor Form


Complete the form below to become a distributor. All fields in red are required.

   
Your Company / Business Name:
Your Name:
Your Position / Title:
Phone:
Fax:
Email:
Website:
Address:
City:
State:
Zipcode:
 
 



SUBMIT

Please make sure to enter the RECAPTCHA code above before clicking SUBMIT. If you can't see the characters clearly, click the double arrows icon to the right of the text box to generate a new RECAPTCHA code.
Which products are you interested in?
Hold down the CTRL key to select multiple values
Where do you focus your sales efforts? (e.g. Hospitals, Government, OTC, etc...)
Your approximate annual sales and the number of salespeople?
What kind of distributorship are you looking for with ACON? (e.g. ACON, OEM, others)
Do you currently sell urine strips, urine strip readers, hemoglobin meters?
If yes in the previous question, who is the manufacturer?
Which local or national exhibitions do you attend?
How did you hear about ACON?
If from the internet, which search engines & what search words?
What information or samples do you need from ACON?
 
 
 
 
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