Agency Request

To request agency, please fill out the following form so that we can contact you
in the shortest possible time after approving the information.

"*" indicates required fields

Name of company

Name of person*

Province

County

Contact number*

Email address*

Address of the shop

Warehouse measuring area

Number of sales representative per line (Line 1 – Line 2 – Line 3)

Number of retail subscriptions in the province

Number pharmacy and drugstore subscriptions in the province

Distribution basket in each line (line 1 - line 2 - line 3)

Number and specifications of distribution vehicles

Number of active retail subscriptions in the province

Number active pharmacy and drugstore subscriptions in the province

Number of wholesale subscriptions

Number of active wholesale subscriptions

Work records

Information