PARTNERSHIP REQUEST FORM

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NAME OF ORGANIZATION  
 
TYPE OF ORGANIZATION  
 
PRODUCTS/SERVICES  
 
YEAR OF ESTABLISHMENT  
 
WORLD WIDE BRANCH*  
 
COUNTRY OF REGISTRATION  
 
E-MAIL ADDRESS, WEBSITE  
 
CORPORATE ADDRESS,
PHONE, FAX
 
 
SPECIAL REMARKS  
 
ENVISAGED OR PROPOSED AREAS
OF COLLABORATION
 
 
NAME OF REPRESENTATIVE  
 
POSITION  
 
PERSONAL PHONE NUMBER  
 
DATE  
 
     
* WORLD-WIDE BRANCH DISTRIBUTION: PLEASE STATE COUNTRIES WHERE YOUR BRANCHES OPERATIONS ARE LOCATED