aurolab

Distributor Registration Form

Your Company Information

*Name of Company:	Country:
President/CEO/Owner:	*Email:
*Principal Contact:	Website:
Address:	*Phone:
	Fax::
	Cell:
* Denotes required fields.

Company Background/Capacity

Which territories does your company cover?

How many years has your company sold?
Medical Products:
Opthalmic Products:

Is it necessry to register/certify medical devices or ophthalmic products in your country?
Yes: No:

If Yes:

Has your company ever registered medical devices before?

Yes: No:

How long does the registration process take?

Are you aware of the fees associated with registration?
If Yes, what is the calculated fee:

Does your country honor CE or ISO 9001 Certifications?

Yes: No:

How many sales representatives do you have?

Total employees:

Does your company currently sell any of the following ophthalmic products? Yes No

	Brand/Type	End User Price
PMMA IOL
Single Piece Acrylic IOL
Three Piece Acrylic IOL
Single Use Instruments
Blades
Stainless Instruments
Viscoelastic Solutions
A Scans
Phaco Equipment

What was your total company sales volume last year?

In $USD:

What was your total ophthalmic sales volume last year?

In $USD:

Estimated Monthly Volumes for Aurolab's Products

	# Pieces
PMMA IOL
Single Piece Acrylic IOL
Three Piece Acrylic IOL
Viscoelastic Solutions:	(choose below)
1% Sodium Hyaluronate
1.4% Sodium Hyaluronate (High Viscosity)
1.8% Sodium Hyaluronate (Bacteria Fermented)
2.5% Sodium Hyaluronate (Viscoadaptive)
2% Methyl Cellulose
2% Methyl Cellulose & 2% Chondroitin Sulfate
2% Sodium Hyaluronate & 2% Chondroitin Sulfate.
Tension Rings
Sutures:	(choose below)
Nylon
Silk
Polypropelene
Polyester
PGA (Poliglicolic Acid)
Plastic Injectors
Titanium Injectors
Tripan Blue
Drapes
Single Use Instruments
Blades
Phaco Equipment
Scan A Equipment

Company References (Preferably US Companies)

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Additional Information - Provide any additional information you feel may be needed for your application.

Thank you for your interest in joining the e-Aurolab team! Please verify that this application has been completed and click submit (preferred) or download a form and fax it to us. We will contact you shortly.