Agency Application Form

Name of company or distributor
Registered capital (RMB10,000 yuan)		Legal representative
Annual sales value (RMB10,000 yuan)		Number of sales personnel
Company address
Bank of deposit
Account name
Account number
Nature of enterprise	State-ownedPrivateSubsidiary
Company Tel		Company Fax
Business contact person		Mobile telephone
Recipient’s address
Name and telephone of recipient
Agent of our company’s products	Keyes
Previous successful agent products
Commodities delivered
Current coverage area and/or hospital
Opinion of Business Manager
Remarks