Distributor Inquiry Form

The purpose of the ELECTRA MEDICAL Distributor Application is to ensure that the present and future responsibilities of the applicant are accurate and documented in a confidential manner. Its contents will be disclosed only to Electra Medical Corp.

Business Information:

Company Name:
Contact Person:
Address:
City/State/Zip:
Phone:
Fax:
E-mail:
Shipping Address:
How many years has your company been established?

Please tell us what products you are interested in for distribution:
To select more than one item, hold down the "control" key.

Centrifuges	Hema11000 Reliacen I Reliacen II Versatil
Laboratory Incubators	EM055 (1.94 cu. ft.) EM055 (4.2 cu. ft.) EM400 (1.6 cu. ft.) EM400P (1.5 cu. ft.) EM500 (4.2 cu. ft.) EM500P (3.9 cu. ft.) EMC110 (3.9 cu. ft.) Refrigerated EMC250 (9.3 cu. ft.) Refrigerated
Sterilizers- Dry Air	EMS300 (0.76 cu. ft.) EMS400 (1.6 cu. ft.) EMS400P (1.5 cu. ft.) EMS500 (4.2 cu. ft.) EMS500P (3.9 cu. ft.)
Ovens	EM0200 (6.8 cu. ft.) EM0400 (13. cu. ft.) EMV018 (0.53 cu. ft.)
Steam Sterilizers	EMS032 (1.5 cu. ft.) with Vacuum Drying Function EMS0120 (0.42 cu. ft.) EMS4060 (2.6 cu. ft.) EMS4060V (2.6 cu. ft.) with Vacuum Function
Water Baths	EMB302 (14L) EMB402 (30L) EMB302R (14L) Refrigerated EMB402R (30L) Refrigerated
Blood Gas Analyzers	EasyBloodGas
Electrolyte Analyzers	Easylyte Na/k EasyLyte PLUS Na/K/Cl EasyLyte Lithium Na/K/Li EasyLyte Na/K/Cl/Li EasyLyte Calcium Na/K/Ca/pH
Other Equipment	Blood Bank General Lab Equipment Service Parts

Please check the fields that apply to the Product categories your company currently distributes: You may select as many as you wish.

	Blood Gas Analyzers
	Electrolyte Analyzers
	Hematology Analyzers
	Chemistry Analyzers
	Coagulation Analyzers
	Veterinary Analyzers
	Chemistry Reagents
	Point-of-Care Testing/Instrumentation
	Centrifuges
	General Lab Equipment
	Service Parts

In the spaces provided below, please include product categories and brand(s) not listed that may be considered for future distribution:

Which clinical trade shows has your company participated in the last 3 years?

Which clinical trade magazines has your company advertised in the last 3 years?