Distributor Evaluation Form

GENERAL INFORMATION

Company:

Email:

Name:

Position:

Street Address:

Town/City:

County:

Postcode:

Phone No:

COMPANY INFORMATION

Number of Employees:

Number of Sales People:

Usual Customer Base:  Hospitals Laboratories Primary Care Pharmacies Patient Self Testing

Number of Agents:

Core Business:

Other Diagnostic Companies Represented:

MARKET INFORMATION

Marketplace (Country/region in which you sell):

Population

Hospitals (University/Acute care)

Primary Care Clinics (Including Anticoagulation Clinics)

INR Patients (Total patients on long term Anticoagulation)

INR Reimbursement (in physicians office/patient self test)

Point of Care INR Market Size

PST Market Size (number of patients self testing)

Competitors: Point of Care INR Testing (% of market share)

Forecasted Annual Sales Monitors/Strips:

Year One

Year Two

Year Three

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