Evaluation Form - Welcome to DISA Vascular

							                                                              Kindly fill out the form below
                       MARKET AND COMPANY                    and fax it to Disa Vascular at:
                          ASSESSMENT                               +27 21 448 2163
                                                             or email as an attachment to:
                                                              sales@disavascular.com




                                ABOUT YOUR COMPANY

COMPANY NAME:

PLEASE GIVE US A BRIEF HISTORY OF YOUR COMPANY?


When did your company start?                      How many people does you company employ?




What are you core areas of business?              Where are your offices located?




How and when did you enter the interventional     Can you provide us with bank references?
cardiology market?




PLEASE DESCRIBE THE COMPANY ORGANOGRAM.
Specify the management structure and number of sales, administrative, technical & medically
qualified personnel.




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             THIS INFORMATION WILL BE TREATED AS STRICTLY CONFIDENTIAL
                                        MARKET AND COMPANY ASSESSMENT




WHAT PRODUCTS DO YOU CURRENTLY SELL AND WHAT PERCENTAGE OF
YOUR TURNOVER RESULTS FROM EACH?
Is your focus interventional cardiology? Please specify type products and brand names.

Product                                          % Turnover




PLEASE LIST YOUR CURRENT CLIENTS/TYPE

Client                           Discipline                       Institute




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             THIS INFORMATION WILL BE TREATED AS STRICTLY CONFIDENTIAL
                                          MARKET AND COMPANY ASSESSMENT




HOW MANY CATHETERIZATION LABORATORIES AND CARDIOLOGIST ARE IN
YOUR AREA & WHAT PERCENTAGE OF YOUR BUSINESS RESULTS FROM
RELATIONSHIPS WITH EITHER GOVERNMENT OR PRIVATE HOSPITALS?

Catheterisation Laboratories                      Interventional Cardiologists

Government Hospitals                              Private Hospitals

WITHIN THESE ORGANIZATIONS, WHOM DO YOU DEAL WITH?
Please specify e.g. Theatre Staff, Hospital Administration, Specialist Type etc.




WHAT LEGISLATION IS REQUIRED FOR DISTRIBUTION OF PRODUCTS IN
GOVERNMENT HOSPITALS?




                            ABOUT THE CARDIOLOGY MARKET

WHAT COMPETITOR PRODUCTS ARE DISTRIBUTED IN YOUR REGION?

Competitor                         % Market share                     End user price




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             THIS INFORMATION WILL BE TREATED AS STRICTLY CONFIDENTIAL
                                 MARKET AND COMPANY ASSESSMENT




ARE PRODUCTS SOLD BY CONSIGNMENT? (This information is needed for our trace-
ability system)




HOW MANY PTCA BALLOON CATHETERS ARE USED ANNUALLY?



HOW MANY STAINLESS STEEL CORONARY STENTS ARE USED ANNUALLY?



HOW MANY DRUG-ELUTING STENTS ARE USED ANNUALLY?



HOW MANY CHROMIUM COBALT STENTS ARE USED ANNUALLY?



WHAT ACCREDITATION IS REQUIRED FOR THE IMPORT OF PTCA BALLOON
DILATATION CATHETERS AND MOUNTED CORONARY STENT SYSTEMS IN YOUR
COUNTRY? Can you provide us with full details?




WHAT OTHER REGULATION GOVERNS THE IMPORT OF MEDICAL DEVICES IN
YOUR COUNTRY? What is the taxation rate on medical devices? Does the government
regulate mark-ups?




          DOC: DV-F-01-14               ISSUE 03                      Page 4 of 6

              THIS INFORMATION WILL BE TREATED AS STRICTLY CONFIDENTIAL
                                           MARKET AND COMPANY ASSESSMENT




                                   ENTERING THE MARKET

HOW WOULD YOU PROPOSE INTRODUCING DISA VASCULAR PRODUCTS INTO
THE MARKET?




WHAT DIFFERENTIATES YOUR COMPANY FROM COMPETITOR DISTRIBUTORS?




WOULD YOU WANT TO SELL OUR PRODUCTS REGIONALLY OR NATIONALLY?
Which countries/states/districts/areas/cities are you able to distribute to?




If you intend to sell Nationally
how do you propose to do
this?


How will you represent DISA
Vascular nationally


How many representatives will
you have to focus on DISA
Vascular sales

WHAT SHARE OF THE MARKET WOULD YOU EXPECT TO GET WITHIN THE FIRST
3 YEARS?

Year one                           Year two                            Year three




           DOC: DV-F-01-14                           ISSUE 03                       Page 5 of 6

              THIS INFORMATION WILL BE TREATED AS STRICTLY CONFIDENTIAL
                      MARKET AND COMPANY ASSESSMENT




DOC: DV-F-01-14             ISSUE 03                  Page 6 of 6

   THIS INFORMATION WILL BE TREATED AS STRICTLY CONFIDENTIAL