testAre you looking to become our distributor? *No – I’m only looking to purchaseYes – I’ll fill out the Distributor Application FormDistributorship Application Form Thank you for your interest in becoming a distributor for Mednex. This form is designed to help us understand your business profile and areas of interest. Your information will be kept confidential and used only to assess distributorship eligibility.Full name *Designation *Email *Mobile *WebsitePlease include full address so we can send you relevant product samples or catalogs if needed.Mailing AddressCityStateZip CodeSelect your CountryIndiaUnited StatesUnited KingdomCanadaAustraliaGermanyFranceItalySpainUAESaudi ArabiaQatarKuwaitOmanSingaporeMalaysiaThailandIndonesiaSouth AfricaNigeriaKenyaBrazilMexicoChinaJapanSouth KoreaRussiaTurkeyBangladeshNepalSri LankaPakistanAfghanistanPlease list the products and quantities you're interested in purchasing.ORMy requirement is specified in the attached file(s). If possible, please mention our item codes and quantities.Choose FileNo file chosenDelete uploaded fileEstimated Order Value (Optional)Nature of Business *DistributorWholesalerRetailerOnline SellerGovernment ContractorOtherYears in Business *Number of Employees *Do you have warehouse facilities? *YesNoPlanning to setupDo you have a retail showroom? *YesNoDo you sell online? (E-commerce) *YesNoHow do you plan to promote our products? *Field SalesOnline MarketingDistributorsTenders,OtherFull name *Designation *Company Name *Email *Mobile *WebsitePlease include full address so we can send you relevant product samples or catalogs if needed.Email AddressCityStateZip CodeSelect your Country *CountryIndiaUnited StatesUnited KingdomCanadaAustraliaGermanyFranceItalySpainUAESaudi ArabiaQatarKuwaitOmanSingaporeMalaysiaThailandIndonesiaSouth AfricaNigeriaKenyaBrazilMexicoChinaJapanSouth KoreaRussiaTurkeyBangladeshNepalSri LankaPakistanAfghanistanMarkets Served *HospitalsClinicsDealersPharmaciesE-commerceGovernmentExportOtherYour Annual Turnover / Revenue in US Dollars *<$50,000$50,000–$100,000$100,000–$500,000$500,000–$1M$1M–$5M$5M+Please select the categories you’re interested in. You may choose more than one. *Orthopedic Implants & InstrumentsHospital Furniture & Infrastructure (Beds, stretchers, OT tables, lights, linens)Surgical Instruments & Tools (General, ENT, laparoscopic, etc.)Critical Care & ICU Equipment (ICU beds, ventilators, monitors, emergency gear)Medical Disposables & Consumables (Syringes, gloves, Covid supplies)Diagnostic & Imaging Devices (ECG, ultrasound, X-ray, patient monitors)Sterilization & Disinfection Systems (Autoclaves, UV sterilizers, etc.)Laboratory & Blood Bank Equipment (Microscopes, centrifuges, cold chain)Infant, Neonatal & OB-GYN Care (Warmers, incubators, phototherapy, fetal monitors)Dental, Rehab & Veterinary Equipment (Dental chairs, wheelchairs, physio, veterinary tools)OtherPlease specify which cities/states/countries you would like to cover as a distributor. *Do you currently represent any other medical companies or brands? *YesNoPlease list the companies you represent, the product categories, and whether your agreements with them are exclusive or non-exclusive. *How did you find us? *GoogleTrade ShowReferralSocial MediaEmailAlready a customerOtherPlease select the categories you’re interested in. You may choose more than one. *Orthopedic Implants & InstrumentsHospital Furniture & Infrastructure (Beds, stretchers, OT tables, lights, linens)Surgical Instruments & Tools (General, ENT, laparoscopic, etc.)Critical Care & ICU Equipment (ICU beds, ventilators, monitors, emergency gear)Medical Disposables & Consumables (Syringes, gloves, Covid supplies)Diagnostic & Imaging Devices (ECG, ultrasound, X-ray, patient monitors)Sterilization & Disinfection Systems (Autoclaves, UV sterilizers, etc.)Laboratory & Blood Bank Equipment (Microscopes, centrifuges, cold chain)Infant, Neonatal & OB-GYN Care (Warmers, incubators, phototherapy, fetal monitors)Dental, Rehab & Veterinary Equipment (Dental chairs, wheelchairs, physio, veterinary tools)OtherIf approved as a distributor, what is the estimated value of your initial order (in USD)?If approved, how soon would you be ready to place your first order? *A: ImmediatelyB: Within 1 monthC: 1-3 monthsD: Can't sayHow did you find us? *Google SearchTrade Show / ExpoReferral from an Existing DistributorSocial Media (LinkedIn, Instagram, etc.)Email CampaignAlready a CustomerOtherUrgency of Order *Immediate1–2 Weeks1 Month3 MonthsJust Collecting InformationOptional – Please provide any additional information *Optional - Upload Tenders, Requirement, Supporting Documents etc.Choose FileNo file chosenDelete uploaded fileComments (optional)Submit