ALLENGERS MEDICAL SYSTEMS LIMITED AMSL/F/EXP/20

Dealer Application Form Rev. No.03, Eff. Date:28.04.21

Please answer to all questions mentioned in below Table:

Legal Business Name

Business Address
Contact Person
City and Country
Zip
Telephone No.
Mobile No.
Email address:
Website
Corporation ____
LLC ____
Status of Company
Partnership ____
Sole Proprietorship ____
Any Other:____________

Bank Name:
A/c Holder Name:
A/c No.:
Swift Code:
Company Bank Details Bank Address:
Dealing Since:

Bank Name:
A/c Holder Name:
A/c No.:
Swift Code:
Bank Address:
Dealing Since:

Date of Establishment

Company Turnover in USD

Yes No
Is your Company Registered In your If Yes, please attach the below documents:
Country - Registration Number
- Copy of Company Registration Certificate
- Copy of passport of CEO / Owner

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 ALLENGERS MEDICAL SYSTEMS LIMITED AMSL/F/EXP/20
Dealer Application Form Rev. No.03, Eff. Date:28.04.21

EO / Owner / Partner / Officer (Please Name ____________________________________________________

list up to three) Phone /Mobile No__________________________________________
Home Address_____________________________________________
_________________________________________________________

Name ____________________________________________________
Phone /Mobile No__________________________________________
Home Address_____________________________________________
_________________________________________________________

Name ____________________________________________________
Phone /Mobile No__________________________________________
Home Address_____________________________________________
_________________________________________________________

Trade Reference (1) Name ____________________________________

Phone ____________________________________________________
Address___________________________________________________
Length of relationship ________________________________________

Trade Reference (2) Name ____________________________________

Please provide three trade references Phone ____________________________________________________
Address___________________________________________________
Length of relationship ________________________________________

Trade Reference (3) Name ____________________________________

Phone ____________________________________________________
Address___________________________________________________
Length of relationship ________________________________________

Marketing Servicing Manufacturing

The main activities of your company Other (Give Details)_________________________________________
are:
_________________________________________________________

a) In Sales/ Mktg._______________________________________
Total No. of Employees in your b) In Servicing _____________________________________
organization c) Others__________________________________________
d) Total No. of Employees____________________________
Name the Companies being 1. ______________________________
represented by you at present 2. ______________________________
3. ______________________________
4. ______________________________
Are you sole representative of said Yes No
company?

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 ALLENGERS MEDICAL SYSTEMS LIMITED AMSL/F/EXP/20
Dealer Application Form Rev. No.03, Eff. Date:28.04.21
(Kindly select appropriate box in questionnaire)
Product Category/ Have you ever Are you interested to Is the product
Name of Product promoted mentioned promote our product Manufactured /Assembled
products range? range mentioned? in your country?
Product Range: Radiology
Digital Radiography Systems Yes No Yes No Yes No
(DR) Systems (Mobile/Fixed)
Make:___________
_________________

Remote Controlled RF Table Yes No Yes No Yes No

(Digital/Analog)
Make:___________
_________________

Digital Subtraction Yes No Yes No Yes No

Angiography Systems
Make:___________
_________________

Mammography Full Field Yes No Yes No Yes No

(Digital/Analog)
Make:___________
_________________

Digital Radiography Retrofit Yes No Yes No Yes No

Systems
Make:___________
________________

HF/LF X-Ray Machines Yes No Yes No Yes No

(Mobile/Fixed)
Make:___________
_________________

Product Range: Ortho, Gastro, Neuro Surgery and Interventional

High Frequency C-Arm Yes No Yes No Yes No
(I.I/FPD)
Make:___________
_________________

Product Range: Cardiology

Fixed Cathlabs (I.I/FPD) Yes No Yes No Yes No

Make: ___________
_________________

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 ALLENGERS MEDICAL SYSTEMS LIMITED AMSL/F/EXP/20
Dealer Application Form Rev. No.03, Eff. Date:28.04.21
Mobile Cathlabs (I.I/FPD) Yes No Yes No Yes No
Make:___________
_________________

STRESS ECG (TMT) Yes No Yes No Yes No

Make:___________
_________________

Patient Monitors/ Vital Sign Yes No Yes No Yes No

Monitor (MPM)
Make:___________
_________________

Electrocardiograph (ECG) Yes No Yes No Yes No

Make:___________
_________________

Product Range: Neurology

Electroencephalograph (EEG) Yes No Yes No Yes No

Make:___________
_________________

Polysomnograph Yes No Yes No Yes No

(Sleep Study) (PSG)
Make:___________
_________________

Electromyograph (EMG) Yes No Yes No Yes No

Make:___________
_________________

Product Range: Urology

Holmium Yag Laser Yes No Yes No Yes No

Make:___________
_________________

Product Category: IT Solutions

Picture Archiving & Yes No Yes No Yes No
Communication System (PACS)

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 ALLENGERS MEDICAL SYSTEMS LIMITED AMSL/F/EXP/20
Dealer Application Form Rev. No.03, Eff. Date:28.04.21

1. ______________________________
Which Brands are already 2. _____________________________
available in your country for our
3. ______________________________
above given product range
4._______________________________
Health care is provided mainly Government business______ % age
through Govt. Hospitals & Private
Hospitals? Private business_______ % age
Do you specialize in private Private Government Both
business or government business
or both?
Operating on National / Regional National Regional
Level Area.
Yes No
Registration Period: ___________
Is registration required for our Documents/ Certificates required for Registration
type of products before selling in 1. _____________________________________
your country?
2. _____________________________________
3. _____________________________________
a ) Custom (Import) Duty ___________%age
What are the %age of expenses of b) VAT (Sales Tax) ______________%age
sales margins? c) Custom Clearance ___________%age
d) Logistics/Installation & Warranty Expenses _________%age
e) Sales Margin _____________%age
f) Any other __________________
Option 1:
Phase to Phase Voltage: 220V, 60Hz -AC Supply
Power Supply Available in Phase to Neutral Voltage: 110V, 60Hz - AC Supply
Your Country Option 2:
Phase to Phase Voltage: 380-440V, 50/60 Hz -AC Supply
Phase to Neutral Voltage: 220V, 50/60 Hz - AC Supply
Any special comments you wish to
give about your company
Are you interested to purchase a Yes No
demo unit?
Which product you would like to
purchase as a demo unit
Thank you for showing your interest to associate with our company. Please fill out this application and send it to our
e-mail ID: exports@allengers.net. Our analysis department will analyze your application and once it is approved
then we will send you draft of dealership agreement.

Signature:

Name: Date:

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