Distributor Registration

Use the form below to request a new account. You will be contacted when administrators approve your request.

Title *

* Indicates required field

Name *

First

Last

Company *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone *

Fax *

Email *

Website *

Describe your company ownership/structure. *

What territory does your distributorship currently cover? *

Do you currently sell to spine surgeons? *

If yes, approximately for how many years have you sold to spine surgeons? *

If yes, how many spine surgeons do you actively sell to at this time? *

How many hospitals do you sell to at this time? *

What is your current hospital/end-user pricing in the sectors below for the primary spine implant categories (e.g. pedicle screws, MIS screws, MIS screws with integrated extended tabs, cervical cages, DLIF cages, etc.)?
Enter "N/A" if not applicable.

Government/Public Hospitals and Tenders *

Teaching Hospitals *

Private *

Please list which other spine products you currently represent and duration represented. *

What was your sales volume during the last calendar year?
Enter "N/A" if not applicable.

Government/Public Hospitals and Tenders *

Teaching Hospitals *

Private *

Please provide the following information for your company
Enter "N/A" if not applicable.

Commercial Registration *

MOH Registration *

Import License *

What requirements would there be for SpineCraft to register our products in your market? *

How did you hear about SpineCraft? *

TELEPHONE NUMBER

(877) 731-7746