{"id":19636,"date":"2024-09-28T15:52:00","date_gmt":"2024-09-28T12:22:00","guid":{"rendered":"https:\/\/panberes.com\/agency-request\/"},"modified":"2025-04-19T11:08:00","modified_gmt":"2025-04-19T07:38:00","slug":"agency-request","status":"publish","type":"page","link":"https:\/\/panberes.com\/en\/agency-request\/","title":{"rendered":"Agency Request"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"19636\" class=\"elementor elementor-19636 elementor-15699\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-dca32b2 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"dca32b2\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-3b4745c\" data-id=\"3b4745c\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-e978fe8 elementor-widget elementor-widget-woocommerce-breadcrumb\" data-id=\"e978fe8\" data-element_type=\"widget\" data-widget_type=\"woocommerce-breadcrumb.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<nav class=\"woocommerce-breadcrumb\" aria-label=\"Breadcrumb\">Home<\/nav>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-6694b95 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"6694b95\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-2e97b8f\" data-id=\"2e97b8f\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-48054b6 elementor-widget elementor-widget-text-editor\" data-id=\"48054b6\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<h2 style=\"text-align: center; color: #3d3d3e;\">Agency Request<\/h2><p style=\"text-align: center; color: #54585a;\">To request agency, please fill out the following form so that we can contact you<br \/>in the shortest possible time after approving the information.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-69ab975 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class='gform-body gform_body'><div id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_6_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_6_1\" ><label class='gfield_label gform-field-label' for='input_6_1'>Name of company<\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_6_1' type='text' value='' class='large'    placeholder='Name of company'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_6_2\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_6_2\" ><label class='gfield_label gform-field-label' for='input_6_2'>Name of person<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_6_2' type='text' value='' class='large'    placeholder='Name of person' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_6_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_6_3\" ><label class='gfield_label gform-field-label' for='input_6_3'>Province<\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_6_3' type='text' value='' class='large'    placeholder='Province'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_6_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_6_4\" ><label class='gfield_label gform-field-label' for='input_6_4'>County<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_6_4' type='text' value='' class='large'    placeholder='County'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_6_5\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_6_5\" ><label class='gfield_label gform-field-label' for='input_6_5'>Contact number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_6_5' type='tel' value='' class='large'  placeholder='Contact number' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_7\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_6_7\" ><label class='gfield_label gform-field-label' for='input_6_7'>Email address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_6_7' type='email' value='' class='large'   placeholder='Email address' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_6_9\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_6_9\" ><label class='gfield_label gform-field-label' for='input_6_9'>Address of the shop<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_9' id='input_6_9' class='textarea small'    placeholder='Address of the shop'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_6_11\" ><label class='gfield_label gform-field-label' for='input_6_11'>Warehouse measuring area<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_6_11' type='text' value='' class='large'    placeholder='Warehouse measuring area'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_6_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_6_10\" ><label class='gfield_label gform-field-label' for='input_6_10'>Number of sales representative per line (Line 1 \u2013 Line 2 \u2013 Line 3)<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_6_10' type='text' value='' class='large'    placeholder='Number of sales representative per line (Line 1 \u2013 Line 2 \u2013 Line 3)'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_6_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_6_12\" ><label class='gfield_label gform-field-label' for='input_6_12'>Number of retail subscriptions in the province<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_6_12' type='text' value='' class='large'    placeholder='Number of retail subscriptions in the province'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_6_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_6_13\" ><label class='gfield_label gform-field-label' for='input_6_13'>Number pharmacy and drugstore subscriptions in the province<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_6_13' type='text' value='' class='large'    placeholder='Number pharmacy and drugstore subscriptions in the province'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_6_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_6_14\" ><label class='gfield_label gform-field-label' for='input_6_14'>Distribution basket in each line (line 1 - line 2 - line 3)<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_6_14' type='text' value='' class='large'    placeholder='Distribution basket in each line (line 1 - line 2 - line 3)'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_6_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_6_15\" ><label class='gfield_label gform-field-label' for='input_6_15'>Number and specifications of distribution vehicles<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_6_15' type='text' value='' class='large'    placeholder='Number and specifications of distribution vehicles'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_6_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_6_18\" ><label class='gfield_label gform-field-label' for='input_6_18'>Number of active retail subscriptions in the province<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_6_18' type='text' value='' class='large'    placeholder='Number of active retail subscriptions in the province'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_6_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_6_19\" ><label class='gfield_label gform-field-label' for='input_6_19'>Number active pharmacy and drugstore subscriptions in the province<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_6_19' type='text' value='' class='large'    placeholder='Number active pharmacy and drugstore subscriptions in the province'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_6_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_6_16\" ><label class='gfield_label gform-field-label' for='input_6_16'>Number of wholesale subscriptions<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_6_16' type='text' value='' class='large'    placeholder='Number of wholesale subscriptions'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_6_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description 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