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Please complete the questionaire form if you wish to participate in the Elysian Fields database of global distributors. With the information provided we will be able to evaluate for existing and future projects for devices available for distribution in your region.

First Name*
Last Name/Surname*
Email Address*

Company Information

Company Name*
Post Code
Select Your Country
Website http://

Company Information

Number of Employees*
Annual Turnover/Sales (Please use USD's)
Year Established
Geographic Regions Covered*
How many days of inventory of products is routinely held?
Does the company place products on consignment?
Does the company offer emergency delivery of products?
If yes, what is the time required to deliver an emergency?
Does the company import products into their country?
If yes, where are the products imported from?
Do you service products?
If Yes how many service engineers are employed by the company?
What types of customers do you Target? (Check all that apply)
What is your company's area of specialty? (Check all that apply)*
What Type of products do you carry in these specialty áreas ( i.e. disposables, capital equipment, etc.)*
What percentage of sales is sold enough?
Direct to customer* %
Indirectly through sub-distributors* %
Agent %
What percentage of sales are sold to public institutions / what percentage of sales are sold to private institutions?
Public %
Private %
Number of direct sales personnel
Number of Clinical Specialists
Number of agents
Number of sub-distributors
What percentage of sales is invested in marketing? %
Does the company have a product manager or marketing manager within their structure?
If Yes, please describe the marketing function structure
What marketing methods are employed by the company?
Other Comments


Who is responsible for Regulatory Activities in your company?
Other (specify):
How does your company get updated on New Regulations / changes in Regulations in your company?
Other (specify):
Does your company work with RA consultants?
If YES: Which one?
Does your company have RA Standard Procedures?
If YES: which ones?
Other (specify)
How does your company control expiration of Sanitary Licenses?
RA Software (specify)
Other (specify)
How does your company control IF products imported have sanitary license?
Other (specify)
Does your company participate or is member of any Sanitary Associations/Chambers?
If Yes, Which ones? Who attends the meetings?
How often does your company meet with HA agents?
Other (specify)
Is your company requested to apply over labels on the products?
Is your company requested to have a Technical Responsible to operate?
Is your company plausible to receive HA audits?
If yes: How often?
Does your company manage more than one country?
If yes, specify which one:

Please contact me to discuss the devices you have available for distribution in my area.