APPLICANT'S NAME		Additional infos
ADDRESS
CITY
COUNTRY
STATE
E-MAIL
TELEPHON NUMBER
FAX NUMBER
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IF A COMPANY, THE NAME OF THE INTERESTED PERSON :

PERSON'S FUNCTION IN THE COMPANY


ACTIVITY OF THE COMPANY

WRITE IN DECREASING ORDER THE KINDS OF BAITS YOU ARE MOST INTERESTED IN (indicate the name of the flavour and if it is Traditional, Competition or Liquid)

1)	2)
3)	4)
5)	6)

PLEASE INDICATE YOUR REQUIREMENTS :

• TO RECEIVE ARTICLES WRITTEN BY LEADING FISHERMEN IN FISHING MAGAZINES
  
• TO RECEIVE SAMPLES
  
• YOU ARE DISPOSED TO PAY IN ADVANCE THE FREIGHT COST FOR RECEIVING THE SAMPLES
  

WHICH FISHING EXHIBITIONS DO YOU VISIT?

AIPO
EFTTEX
ASA
FEIPESCA
OTHERS

STATE WHICH

OTHER INFORMATION

OTHER REQUESTS