Application Form for JETRO Business Partnering @ MD&M West 2007

Return this form by January 10, 2007

Company Name	URL:
Address
President		TEL	FAX
Person in Charge		Position
E-MAIL
Product categories	Active implants Aids for the disabled Anesthetic & respiratory devices Dental devices Drug delivery systems Emergency medical equipment　Electro-medical devices Hospital equipment Imaging & radiotherapy devices Ophthalmic & radiotherapy devices Passive implants Single use disposables Surgical appliance Surgical & medical instruments Lab apparatus In-vitro diagnostic Irradiation Other ( )
Organizational Development	Startup　　Research & Development Product in Clinical Trials Shipping Product Profitable Other ( )
Capitalization
No. of Employees
Year established
Main Competitors*
Partners, if any*
Investors/VCs
Brief Description of Business (in 50 words or less):
Technology, Products or Services (including description of competitive advantage, in 50 words or less)
Business Experience with Japan　（please summarize any experience the company has had with Japan, including exports, technology transfers, partnerships or investment）
Japanese Companies particularly interested in meeting*

* Optional questions; answer required for all other questions

Note: JETRO will make every effort to arrange appropriate appointments for companies that apply. It cannot, however, guarantee that appointments will be arranged or that appointments will result in tangible business results.