Distributor Application

Company Name*

Company Address*

This should be the registered company address and should include city and country.

Website Address

Contact Name*

Please enter in the format of Forename, Family Name

Contact Telelphone No.*

International format to include country code e.g. +44 (0) 1234

Email Address*

Country where you wish to distribute*

If you are interested in distribution for more than one country, please indicate which is the primary country of interest.

Which of the following products do you currently supply. Please tick all that apply*

Colposcope

Electrosurgery Equipment

Cervical Sampling Equipment

Gynaecology Chairs/ Tables

HPV Test

Liquid based Cytology Test

Biopsy forceps

Other gynaecology consumables

Other Products

Please list other products below

How did you hear about Zilico / ZedScan

I agree to be contacted regarding my query.*

By opting in you agree that Zilico can keep and maintain your details and contact you regarding its products and services.

Captcha*