Company Name *

Company Website *

Country *

Email Address *

Designation

Which year was the company founded? *

To whom are you selling to? (✔ where applicable) *

Direct to end userDistributor / DealerBoth end user and distributorOther

How many sales representatives does the company have? (✔ where applicable) *

≤ 3 people4 - 10 people> 10 people

How focused is the company in the dental industry? (✔ where applicable) *

≥ 80%50% - 79%≤ 50%

What is the percentage revenue on disposable items e.g. glove, face mask, dam, plastic and non-woven? (✔ where applicable) *

≥ 80%50% - 79%< 50%

Please list the top 5 product brands currently represented by your company *

Are you currently selling gloves? (✔ where applicable) *

YesNo

If yes, which brand(s)?

if yes, who are your major competitors?

if yes, what is the estimated monthly volume? (box of 100 pieces) (✔ where applicable)

< 100,000100,000 - 500,000500,000 - 1,000,000> 1,000,000

What is the company's estimated annual sales figure? (in US dollars) *

Is your company engaged in CSR Program? (✔ where applicable) *

YesNo

If yes, what is the focused area? (✔ where applicable)

Hospital / Health CareGovernmentCommercial / IndustrialLong Term CareClean RoomLaboratoryOther

if other, please state

Additional Comments (Optional)

Please verify that you are human:

(2+5) x 3 = ?