INTERNATIONAL DISTRIBUTOR QUESTIONNAIRE

Please complete and send or fax to the following address: 180 Mount Airy Rd. Suite 201 Basking Ridge, NJ 07920 USA Phone: 908-630-0950 Fax: 908-630-0940 Email: [email protected] Website: www.ccipharm.com

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INTERNATIONAL DISTRIBUTOR QUESTIONNAIRE

I. COMPANY INFORMATION Company Name: Street Address: P.O. Box: City/State/Province: Postal Code: Telephone Number:
Country Code

Country: Main Number

____
Extension, if any

Fax Number:
Country Code

Main Number

Person to Contact: Title: E-mail Address: Mobile Number: Company Website: Please indicate below, your type of business:

Pharmaceutical Manufacturer Broker/Trading Company

Distributor

Marketing Company Other describe below

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II. ORGANIZATION 1) What year was your business established? 2) Indicate number of years in pharmaceutical-related business: 3) In which countries, beside your own, do you provide your services? _______________________________________________________ 4) Is your company a division or subsidiary of another company? If yes, please list the name and location of parent company:

YES NO

5) How many people does your company employ? 6) How many sales representatives are in your company? 7) Does your company sell through independent sales representatives, agents or distributors? YES NO If yes, please provide a brief explanation of the number and type of other sales:

8) Please provide us with your companys sales (in USD) for the following years: 2006 US $ ______________ 2007 US $ ______________ 2008 US $ ______________ 2009 US $ ______________ 9) List the names of the following principal executives: President/CEO: _______________________________________ Managing Director/General Manager: ________________________ Vice President/Manager Sales: ____________________________ Vice President/Manager Marketing: ________________________

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III. SALES & MARKETING 1) How many sales representatives will be selling our products: ___

2) Are these sales representatives experienced in pharmaceutical sales? Yes No 3) Will you hire or appoint a marketing manager for our products? Yes No 4) What pharmaceutical manufacturers and products do you currently represent?

5) What pharmaceutical category (or categories) does your company specialize?

6) How do you promotionally support your product lines in general? Promotions: Advertising: Consumer Magazines In-store events Newspapers Special pricing Trade Magazines Direct-mailings Local Radio Sample support Television Detailing of doctors, dentists, etc Other: ____________ other: ____________ 7) Number of Accounts and Distribution channels Total Number of Accounts: ____________ Of all your accounts, please provide number in each category: Beauty Salons ____ Department Stores ____ Drug Stores ____ Supermarkets ____ Wholesalers ____ Variety Stores ____ Other ____ 8) What markets do you focus on? Government tenders Pharmacies Private Hospitals other: Physicians

9) What are the specific Tariff rates/Import duties on certain pharmaceutical products, such as cosmetics versus pharmaceuticals? 10) Please specify, international sales tax on VAT tax rates: _______________

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IV. PRODUCT INFORMATION Please describe the products you are looking for: _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________

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V. REGISTRATION & LICENSING Product Registration Cost Time Frame

1) Are separate registrations required for each strength or size of a product? 2) How long is a Product License/Marketing Authorization in effect? 3) Can the license be renewed

Yes No

How Long?

Cost?

VI. SALES PROJECTIONS Please complete the table below for sales projections of each product you choose to distribute in your local market. If you wish to go beyond your local market, contact us for additional information. If you need additional space, please use Microsoft Excel to create a larger list.
Sales Projection Product Description 1st Year of Sales 2nd Year of Sales 3rd Year of Sales

1. 2.

Units Units

Units Units

Units Units

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VII. REFERENCES 1) BANK REFERENCE Name of your Bank: Address:

Telephone: Fax: 2) COMMERCIAL REFERENCES (USA if available, otherwise, please provide us with
at least 2 international references)

Business Name: Address:

Contact Name: Contact Telephone:

Business Name: Address:

Contact Name: Contact Telephone: Business Name: Address:

Contact Name: Contact Telephone:

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VIII. ORDER LOGISTICS Ports to be used: AIR: ____________ SEA: ____________ PAYMENT: Who is responsible for payment? Name: Title: Address (if different from your headquarters address)

Telephone: Fax: Email Address: SHIP-TO: Please provide the exact ship-to address for orders Name: Address:

Person to Contact: Telephone: Fax: Email Address: INSURANCE: Is a Certificate of Insurance required with each shipment? Yes No INSPECTION: Is SGS inspection (or other) required? Yes No

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Freight-Forwarder: Please specify if there is a particular freight forwarder that you prefer, use presently or that you have worked with in the past. Name: Address: _____

Person to Contact: Telephone: Fax: Email Address: DOCUMENTS: Please indicate which documents are required with each shipment Commercial Invoice (How many copies?) _____ Airway Bill other _______
THE FOLLOWING INFORMATION MUST ACCOMPANY THIS QUESTIONNAIRE:

_____

Certificate of Origin

Certificate of Analysis

Drug Wholesale License, or Ministry of Health Authorization to Import List of all countries where you are requesting distribution rights. A corporate brochure from your company, if available

Thank you for taking the time to complete this Questionnaire. It is important to us, at CCI, to insure that our distributors are knowledgeable of the market, experienced in sales and marketing, and financially secure to properly support the process. Upon reviewing your information, we will contact you as soon as possible. Please do not hesitate to contact us if you have any questions or comments. Your interest in our pharmaceuticals products is greatly appreciated.

--------See cover page for instructions for returning this Questionnaire to us.-----------