Online Application

PRELIMINARY ONLINE APPLICATION

The following information must be provided in order to apply for becoming a distribution agent of XLTA^® Cure Wound Care Range.

Disclaimer: This preliminary online application does not constitute a contract. Xlta UC LLC reserves the right to accept or reject this preliminary online application at our own discretion. T&C’s apply.

Preliminary Online Application

Once you have completed the online form, we will be in contact with your to confirm details and information. Further terms of service will be discussed with you once your application is successful. By making use of our web site’s online contact form, you hereby give consent to our regarding POPI act and the use of our website. Terms and Conditions apply.

First Name

Last Name

Title

Email Address

Mobile

Company's Telephone

Company Website

Company

Address

City

State

Country

Company's Main Area of Trade

Proposed Represented Region/State

Indicate your Type of Business Indicate your Type of Business Distributor Manufacturer Broker/Trading Company Marketing Company Other describe below

Indicate your Area of Interest Indicate your Area of Interest Distribution Agency Investment

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