COMPANY

Company Name (required)

Email (required)

VAT/Fiscal number of your Company (required)

COMPANY ADDRESS

Street (required)

Postal Code (required)

City (required)

Country (required)

International Phone Number (required)

CONTACTS

Main Contact Name (required)

Position (required)

Phone Number (required)

Commercial Contact Name (required)

Position

Phone Number

Financial Contact Name (required)

Position

Phone Number (required)

Materiovigilance Contact Name (required)

Position (required)

Phone Number (required)

BILLING ADDRESS

Billing Company Name (required)

Street (required)

Postal Code (required)

City (required)

Country (required)

Billing Contact (required)

Phone number billing Contact (required)

Email billing Contact (required)

SHIP TO ADDRESS

Street (required)

Postal Code (required)

City (required)

Country (required)

Phone number (required)

Delivery Contact (required)

Shipping Company name (required)

DELIVERY TERMS

Incoterm (required)
EXWCIPCPT

Type of Transport

Transport Account Number

Customer Contact for Transport (required)

REQUIRED DOCUMENTS FOR SHIPMENT

Certificate of Sterilisation YESNO

Certificate of Analysis / Quality (€30 per batch) YESNO

Certificate of Conformity YESNO

Electronic Certificate of Origin YESNO

EUR1 if more than €6,000 YESNO

Logistic Customized product label (€0.30 per box) YESNO

Additional comments or documents requiring signature/stamp related to preparation, packaging, or shipping:

By submitting this form, I accept that the information entered in this form will be used by the sales department to complete my customer profile. I can delete or modify this data at any time by contacting the company TEKNIMED by mail or by email: rgpd@teknimed.com. More on Legal statements.

By clicking on Send, I have read and accept the general sales terms available -> here