Distributor Application

The information requested below is important in helping Promedicus USA, Inc. comply with the requirements of the laws that govern its business and will be used for that purpose. Complete and accurate answers are required. Answers must be in the English language.

If you have questions about the form, please contact compliance@promedicususa.com.

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Full Legal Name of Organization or Business

Entity Address

Address Line 2

City

State

Zip

Country

Telephone

List all other names under which you have conducted business, including the time period for each:

Business Structure

Country of Organization

Identify ALL owners and any senior executives (Name, Nationality, Owner or Executive, if yes, please specify title, Number of employees).*

Describe Your Business

Number of Years In Business

Describe your territory, and the medical devices in which you specialize, including: (i) your business expertise and familiarity with the market; (ii) any other companies you represent; and (iii) any companies you represent or products that you sell that compete with Merit:

If applicable, list customs agent or broker (name, address, contact telephone):

Are you aware of and agree to abide by the provisions of applicable laws, including but not limited to the US Foreign Corrupt Practices Act (“FCPA”), all other applicable anti-corruption laws, such as the UK Anti-Bribery Act and France’s new “Sapin II” law and any local laws, in providing medical devices and services under the proposed agreement?

Please confirm that you have read and agree to abide by ProMedicus USA’s Code of Ethics and Business Conduct and ProMedicusUSA’s Global Anti-Corruption Policy in providing medical devices and services under the proposed agreement.

Yes, I have understood and agree with the terms of the Code of Ethics and Anti-Corruption Policy.
No

Describe your organization’s compliance program

Does your company have a whistleblower policy, a confidential reporting line via phone and/or online website where people can anonymously question or complain about any unlawful business activities?

Do you do business with government entities (e.g., government-owned hospitals, healthcare centers, pharmacies or university hospitals; or any organizations owned or controlled by any national, provincial or local government)?

If yes, please describe briefly

Do you have at least 5 years of success managing major accounts ( accounts over $500,000 per year?