Overseas Sales Division 12/13/2017 Initial Application

Distributor Application Form

Thank you for your interest in becoming DRGEM’s off icial distributor. Please complete the following Distributor
Application Form with as much detail as possible to apply for a distributorship in your area. The completed
application form should be e-mailed to sales@drgem.co.kr or faxed to +82-2-869-8567.

CONTACT INFORMATION
Name: First Name Last Name
Job Title: E-mail:
Website: Telephone:
Fax: Mobile:

COMPANY INFORMATION
Company:
Address: Street Address City _ ___
State/Province Zip Code Country
Year of Establishment: Core area of business:
Geographical area covered:
Number of Sales People: Number of Engineers:
Total Sales in the Last 12 Months (USD): Estimated Sales Revenue of Current Year (USD):
X-ray Products/Manufacturers currently represented:
Manufacturer Name *Product Lines Territory Sold

*Product Lines: Radiography Room, Chiropractic, Veterinary, Digital Radiography, Other (Please detail)

Provide a short brief of your company’s history:

Tell us about your expertise in the x-ray industry:

1/2
Overseas Sales Division 08/24/2017 Initial Application
MARKET INFORMATION
Population: Approximate market size in USD:
No. of X-ray Systems installed: No. of X-ray Systems purchased yearly:
Ratio of public market/private market:
Major Competitors:
Manufacturer Name Market Share (%) Turnover (USD)

0.00%
0.00%
0.00%
0.00%
0.00%

Marketing strategy to promote DRGEM Products:

OTHERS
How were you referred to DRGEM?
Which of our products are you interested in representing? :
Estimated Forecast for the following year (# of units or amount in USD):
Are you looking for EXCLUSIVE distributorship? : Yes / No
Other requests:

I hereby certify that the above information is true and correct to the best of my knowledge. I understand that any
false information given in the application may disqualify me for distributorship. If a distributorship agreement is
entered, any false misleading information will result in immediate termination of the distributorship. I agree to keep
conf idential any information and materials provided by DRGEM Corporation.

Signature of Applicant (type your name to indicate an e-signature) Date

Print Name & Titles

2/2