Company Name

Primary Contact Name

Email Address

Phone Number

Company Address

Website

Number of Years in Business

Number of Staff

Territories

List the Countries and States you currently distribute to

Annual Revenue

Specify currency:

Product Range

Please list the Brands and Products you currently distribute:

Reseller Accounts

Please provide number of current accounts along with the account names and standings, ex: Retail Location, Pharmacy, Small Resellers, etc:

Distribution Model

What channels and methods you plan to use to distribute our products? List any websites if you plan to sell online:

Future with Relumins

Tell us your future business plan with our Relumins products:

Select Brands You Intend To Distribute