Company name: ……………………................….
Legal representative: ………………....…………..
Function: …………………………..........……….
Tel: ……………………………...........................
Fax: ………………………..................................
Mobile telephone: …………………......................
E-mail: …………………………….............…….
Company address: ………………………………
Date of constitution of the company: ……………………………..
National identification number: ……………………….........……..
Names and functions of those empowered as executives of the company:
1. …………………………………
2. ………………………………....
3. ………………………………....
Activities of the company: ………………………………..
Form(s) of collaboration sought:
Partnership
Research for distribution agreements
Other form of collaboration (please specify): .......................................................
Place, date and signature
Representative of the company
ABC, Africa Business Center S.A.
5, boulevard Royal
L-2449 Luxembourg
Tel.: (+352) 26 73 89 82
Fax: (+352) 26 73 89 83
