Contact Name *

First Name

Last Name

Company Address *

Address 1

Address 2

City

State/Province

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Country

Phone *

Country

(###)

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Do you have your own resources for translating and adapting basic marketing materials such as literature for your own markets?

Yes

No

Are you familiar with all the customs and tax regulations pertaining to the territory?

Yes

No

Company 1 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Company 1 Contact Name

First Name

Last Name

Company 1 Phone

Country

(###)

###

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Company 2 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Company 2 Contact Name

First Name

Last Name

Company 2 Phone

Country

(###)

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