Protected: Distributor Application

The information requested below is important in helping Merit Medical Systems, 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 [email protected].

  • 1. IDENTIFYING INFORMATION

  • NameYears 
    Click the plus button to add additional names/years.
  • 2. BUSINESS STRUCTURE AND OWNERSHIP INFORMATION

  • 3. BUSINESS INFORMATION

  • (c) 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:
  • 4. LEGAL AND COMPLIANCE INFORMATION

  • (b) Please confirm that you have read and agree to abide by Merit's Code of Ethics and Business Conduct and Merit Medical’s Global Anti-Corruption Policy in providing medical devices and services under the proposed agreement.
  • Max. file size: 50 MB.
  • Max. file size: 50 MB.
  • Max. file size: 50 MB.
  • 5. ADDITIONAL INFORMATION

  • CERTIFICATION

  • By clicking the “SUBMIT” button below, you certify that: (1) To the best of my knowledge, all information set forth in this Application is correct and complete; and (2) I will notify the local Merit representative immediately in writing of any change in the information (other than address or contact details) set out in this questionnaire.

    *Merit Medical will carefully review your application, and contact you once a decision has been made. If approval is given, Merit will forward the Distribution Agreement for your review and feedback.
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