E-Mail:

Full name:

Position / title:

Your Company / Business Name:

Address:

City:

Country:

Phone (include area code):

ZIP:

Fax (include area code):

Your Company / Business website:

Your approximate annual sales & the number of sales people:

In which magazine are you doing advertising?

Which local or International exhibitions do you attend:

If yes, who is the manufacturer:

Do you currently sell Antibodies:

What kind of distributorship are you looking for with Aczon:
(OEM, Non-exclusive, Exclusive, Sales Representative)

Where do you focus sales efforts:
(E.G.  Hospital, Research Centers, etc)

In which country/countries do you focus your sales efforts:

Which products are you interested in:

If from Internet, which search engines & what search words:

How did you hear about Aczon:

What information or samples do you need from Aczon:

I declare that, following Law n.675/96 I authorise the disclosure of my personal data to ACZON SpA for purposes related to the operation of the services. I also declare that I am fully aware of the rights I am entitled to following article 13 of the Law 675/96.