Export - FranceMed Pharma

EXPORT FORM FOR POTENTIAL DISTRIBUTORS
To accompany Company Presentation
(emailed separately to Export@francemedpharma.com)

* Indicates required field

Name *

First

Last

Position *

Company Name *

Email *

Tel. No. *

Town, Country *

website *

Size of Business & T/O *

Number of Sales Reps. *

Number of Medical Reps. *

Years in Business *

Number of outlets supplied *

Distribution Network and Type of outlets supplied: Pharmacies, Supermarkets, Hospitals, Doctors.... Other *

Products/brands you currently distribute exclusively. State whether the products are ethical drugs, OTC, personal care or other. *

The Doctors visited by your Medical Reps. *

Which Therapeutic Fields e.g. Dermatology, Paediatrics, Gynaecology..etc are you interested in or work mainly in? *

Which FranceMed Pharma brands/Products listed in this website are of interest to you? *

Submit

var _gaq = _gaq || []; _gaq.push(['_setAccount', 'UA-7870337-1']); _gaq.push(['_setDomainName', 'none']); _gaq.push(['_setAllowLinker', true]); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); _W.Analytics = _W.Analytics || {'trackers': {}}; _W.Analytics.trackers.wGA = '_gaq'; ;(function(p,l,o,w,i,n,g){if(!p[i]){p.GlobalSnowplowNamespace=p.GlobalSnowplowNamespace||[]; p.GlobalSnowplowNamespace.push(i);p[i]=function(){(p[i].q=p[i].q||[]).push(arguments) };p[i].q=p[i].q||[];n=l.createElement(o);g=l.getElementsByTagName(o)[0];n.async=1; n.src=w;g.parentNode.insertBefore(n,g)}}(window,document,'script','//cdn2.editmysite.com/js/wsnbn/snowday262.js','snowday')); var r = [99, 104, 101, 99, 107, 111, 117, 116, 46, 40, 119, 101, 101, 98, 108, 121, 124, 101, 100, 105, 116, 109, 121, 115, 105, 116, 101, 41, 46, 99, 111, 109]; var snPlObR = function(arr) { var s = ''; for (var i = 0 ; i < arr.length ; i++){ s = s + String.fromCharCode(arr[i]); } return s; }; var s = snPlObR(r); var regEx = new RegExp(s); _W.Analytics = _W.Analytics || {'trackers': {}}; _W.Analytics.trackers.wSP = 'snowday'; _W.Analytics.user_id = '23533560'; _W.Analytics.site_id = '831352365279194172'; // Setting do not track if the GDPR cookie is not present. This is then checked by the snowday initializer // to set tracking decisions. https://github.com/snowplow/snowplow-javascript-tracker/blob/2.6.2/src/js/tracker.js#L1509 window.doNotTrack = document.cookie.indexOf('gdpr-kb') === -1 ? 'yes' : null; var drSegmentsTag = document.getElementById('drSegments'); if (drSegmentsTag) { _W.Analytics.spContexts = _W.Analytics.spContexts || []; var segmentData = JSON.parse(drSegmentsTag.innerText); segmentData.forEach(function(test) { _W.Analytics.spContexts.push({ schema: "iglu:com.weebly/context_ab_segment/jsonschema/1-0-0", data: { test_id: test.name, segment: test.variant, } }); }); } (function(app_id, ec_hostname, discover_root_domain) { var track = window[_W.Analytics.trackers.wSP]; if (!track) return; track('newTracker', app_id, ec_hostname, { appId: app_id, post: true, platform: 'web', discoverRootDomain: discover_root_domain, cookieName: '_snow_', contexts: { webPage: true, performanceTiming: true, gaCookies: true }, crossDomainLinker: function (linkElement) { return regEx.test(linkElement.href); }, respectDoNotTrack: document.cookie.indexOf('gdpr-kb') === -1 }); track('trackPageView', _W.Analytics.user_id+':'+_W.Analytics.site_id, _W.Analytics.spContexts); track('crossDomainLinker', function (linkElement) { return regEx.test(linkElement.href); }); })( '_wn', 'ec.editmysite.com', true ); (function(jQuery) { try { if (jQuery) { jQuery('div.blog-social div.fb-like').attr('class', 'blog-social-item blog-fb-like'); var $commentFrame = jQuery('#commentArea iframe'); if ($commentFrame.length > 0) { var frameHeight = jQuery($commentFrame[0].contentWindow.document).height() + 50; $commentFrame.css('min-height', frameHeight + 'px'); } if (jQuery('.product-button').length > 0){ jQuery(document).ready(function(){ jQuery('.product-button').parent().each(function(index, product){ if(jQuery(product).attr('target') == 'paypal'){ if (!jQuery(product).find('> [name="bn"]').length){ jQuery('<input>').attr({ type: 'hidden', name: 'bn', value: 'DragAndDropBuil_SP_EC' }).appendTo(product); } } }); }); } } else { // Prototype $$('div.blog-social div.fb-like').each(function(div) { div.className = 'blog-social-item blog-fb-like'; }); $$('#commentArea iframe').each(function(iframe) { iframe.style.minHeight = '410px'; }); } } catch(ex) {} })(window._W && _W.jQuery); window._W.isEUUser = false; window._W.showCookieToAll = "";