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Distributor Form

Complete the form below to become a distributor. All fields in red are required.

Your Company / Business Name:
Your Name:
Your Position / Title:


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Which products are you interested in?
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Where do you focus your sales efforts? (e.g. Hospitals, Government, OTC, etc...)
Your approximate annual sales and the number of salespeople?
What kind of distributorship are you looking for with ACON? (e.g. ACON, OEM, others)
Do you currently sell urine strips, urine strip readers, hemoglobin meters?
If yes in the previous question, who is the manufacturer?
Which local or national exhibitions do you attend?
How did you hear about ACON?
If from the internet, which search engines & what search words?
What information or samples do you need from ACON?
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