Medical Aesthetics Distributor Form

DISTRIBUTOR APPLICATION FORM

Thank you for your interest in Medical Aesthetics Ltd (MA). This Distributor Application Form is designed to help us get to know you and hopefully,
to establish a business relationship.

MINIMUM REQUIREMENTS TO QUALIFY
If your company wishes to qualify as a MA distributor, or as a sub-distributor, we request that you have the following:

An established channel of distribution appropriate for this type of product line
Representatives adequate to service the specified territory
An infrastructure for ordering, warehousing, and shipping
Resources to adapt marketing and promotional material
Familiarity with export/import regulations pertaining to the territory
An approved business plan for developing the territory
Sufficient capitalization to meet the business plan objectives

EXCLUSIVITY
All distribution agreements are presently on a non-exclusive basis. Final exclusivity will be assigned on a performance basis.

CLIENT ACCOUNT DATA
Name*
Title
Company
Address
City
Prov/State
Postal Code*
Country
Phone
Fax
Email*

REQUESTED TERRITORY Please specify the territory you are applying for and include the principal region and city within that territory. The reason for this is that the country may be assigned to another distributor, but you may qualify as a sub-distributor for a particular area
Country
Region
Major City
PRESENT CHANNELS OF DISTRIBUTION Whom do you presently sell to, or are qualified to sell to?

MARKET SERVED How many dermatologists and skin care professionals are there in your market and how many of them do you sell to?

PRODUCTS PRESENTLY DISTRIBUTED What products do you presently distribute? Are there any possible conflicts?

SIZE OF BUSINESS Can you tell us about the size of your business - how many people do you employ, what are your approximate annual sales?

COMPETITORS Who are your largest competitors, how do you rank in size, and what are your competitive differences?

WAREHOUSING Do you have your own warehousing, packing and shipping facilities? Please describe. MA products must be kept in a clean, secure, temperature-controlled area.

CUSTOMS Are you familiar with all the customs and tax regulations pertaining to the territory? Remember, we sell F.O.B. Also, who is your customs broker?

SPECIAL IMPORT REQUIREMENTS Are there any special government registrations required of MA products before you can import them into your country? Are you able to comply with these requirements?

YOUR SALES FORCE Please tell us a little about your representatives and their qualifications to sell a product like MA. Which territories do each presently handle?

MORE ABOUT YOU It would also be helpful to know about your own qualifications and why you feel they are appropriate for representing MA.

MORE ABOUT YOUR COMPANY Do you have other shareholders or partners? Could you please tell us a little about them and the role they play in your business.

MARKETING & PROMOTION Do you have your own resources for translating and adapting basic marketing materials for your own markets? It is our expectation that distributors produce marketing materials in the language(s) of their country/territory.


FORECAST Forecasting is always difficult, but we require some indication of the size of market you intend to pursue. Please indicate your target volume of orders - from MA. Please state a range from low to high.
year one
low
high

year two
low
high

year three
low
high
BUSINESS APPROACH Please outline your basic business approach and timetable for achieving this forecast.


INFORMATION ON Medical Aesthetics Ltd. As an applicant, we are limited to the amount of information we can provide you at this time. More in-depth and technical information will be provided to qualified distributors upon request. TIMING Please allow several weeks for MA Ltd. to review your company's application. CONFIDENTIALITY We respect that you are submitting this application in confidence. Therefore, MA Ltd. agrees not to disclose any of the contents to any other company or individual outside of our company without your expressed approval. THANK YOU We sincerely appreciate the time and interest you have taken in completing this application and look forward to speaking with you.