Page | 1
DEALER CREDIT APPLICATION
Please type or print legibly. All sections must be completed entirely. Attach any additional pertinent information or schedules.
BUSINESS INFORMATION
Legal name of business/company:
Month/Year business started: Parent company:
Legal form: Corporation Sole proprietorship General Partnership Individual LLC Other:
*(US) Federal tax ID#:
(CA) GST#: (CA) PST#:
(CA) HST#:
* For US dealers, please attach your Sale and Resale Certificate with this credit application form.
Buying group affiliation: Yes No Name of Buying Group:
Billing/mailing address:
City: Prov./State: Postal/Zip Code:
Country: Phone: Fax:
Website address:
Corporate/Parent address (If different from billing address):
City: Prov./State: Postal/Zip Code:
Country: Phone: Fax:
Line(s) of business: DME HME Full Line Dealer Homecare Internet sales Rehab Repair
(
Select all that apply)
Nurs
ing Home/Hospital
W
holesaler Other (Please specify):
Have you ever filed for bankruptcy? Yes No
AMYLIOR product interest:
Power wheelchairs Se
ating Walking Aids Scooters Manual Wheelchairs Batteries Aftermarke
t
Spare Parts Other:
SHIPPING INFORMATION
Please indicate type of loading/unloading configuration for each location.
SHIPPING LOCATION #1
Loading dock Forklift Other (Please specify):
Address: (If different from billing address)
City: Prov./State: Postal/Zip Code:
Phone: Fax:
SHIPPING LOCATION #2
Loading dock Forklift Other (Please specify):
Address:
City: Prov./State: Postal/Zip Code:
Phone: Fax:
If more than two shipping locations, please attach a list of addresses and loading/unloading configuration.
COMPANY PRINCIPALS
OFFICERS, OWNER(S) AND/OR PARTNERS (CEO, CFO, A/P, ETC.)
Name: Title:
Name: Title:
Name: Title:
Number of sales reps (ATPs): Number of employees:
TRADE REFERENCES
Supplier name Account number. Telephone number Fax number
MK - TMK190530-1 June 2019 (Rev01)
SEND BY EMAIL
Page | 2
DEALER CREDIT APPLICATION (continued)
CONTACT MASTER FILE
1. C
ontact name: Title:
Phone: Ext.: Email address:
Fax: Website:
Primary duties/Department: Executive/Owner A/P Customer Service Technical Support Dealer Sales (ATP)
(Please X appropriate box) Purchasing Physiotherapist Occupational Therapist Other: ___________________
Business address, City, Province/State, Postal/Zip Code:
2. C
ontact name: Title:
Phone: Ext.: Email address:
Fax: Website:
Primary duties/Department: Executive/Owner A/P Customer Service Technical Support Dealer Sales (ATP)
(Please X appropriate box) Purchasing Physiotherapist Occupational Therapist Other: ___________________
Business address, City, Province/State, Postal/Zip Code:
3. C
ontact name: Title:
Phone: Ext.: Email address:
Fax: Website:
Primary duties/Department: Executive/Owner A/P Customer Service Technical Support Dealer Sales (ATP)
(Please X appropriate box) Purchasing Physiotherapist Occupational Therapist Other: ___________________
Business address, City, Province/State, Postal/Zip Code:
4. C
ontact name: Title:
Phone: Ext.: Email address:
Fax: Website:
Primary duties/Department: Executive/Owner A/P Customer Service Technical Support Dealer Sales (ATP)
(Please X appropriate box) Purchasing Physiotherapist Occupational Therapist Other: ___________________
Business address, City, Province/State, Postal/Zip Code:
5. C
ontact name: Title:
Phone: Ext.: Email address:
Fax: Website:
Primary duties/Department: Executive/Owner A/P Customer Service Technical Support Dealer Sales (ATP)
(Please X appropriate box) Purchasing Physiotherapist Occupational Therapist Other: ___________________
Business address, City, Province/State, Postal/Zip Code:
MK - TMK190530-1 June 2019 (Rev01)
Page | 3
DEALER CREDIT APPLICATION (continued)
BANK REFERENCES
Bank name and branch Telephone. Bank manager Account number (s)
****** The following section must be completed *****
PURCHASING INFORMATION
Based on Amylior product interest selected on page 1, what manufacturers are you currently purchasing from, and why?
What percentage of your business is dedicated to these products?
Average monthly sales: $ Estimated yearly sales: $
Estimated monthly orders from AMYLIOR Number of units:
Dealership overview information:
FINANCIAL INFORMATION
Estimated average monthly purchases from AMYLIOR over the next 12 months: $
If credit requirements are expected to exceed $50,000, please submit a copy of your last annual financial statement or your
most recent tax return.
Applicant’s name: Application date:
TERMS & CONDITIONS
C
ONDITIONS UNDER WHICH CREDIT ACCOUNT I
S
G
RANTED
:
1. Dealer shall conduct business with AMYLIOR as well as its customers in a fair and ethical manner.
2. Dealer agrees to provide support for AMYLIOR products in pre-sales promotions, direct customer support and after sale
follow-up service when necessary. This includes product warranty service.
3. Dealer is required to keep his account in good standing within the terms agreed upon
.
4. Minim
um annual purchases of 10,000 $ dealer net are required to retain dealer credit account status.
5. Dealer must comply with all rules and regulations set forth by AMYLIOR, in any documents governing AMYLIOR’S busine
ss
with
its custom
ers.
6. Con
ditions subject to change at AMYLIOR discretion with written notice.
BY SIGNING THIS APPLICATION FOR CREDIT, DEALER UNDERSTANDS AND AGREES TO THE FOLLOWING:
If an open line of credit is approved, Dealer understands that Dealer will be assigned trade credit terms. Dealer agrees to
pay account within these term
s.
Deal
er understands that AMYLIOR reserves the right to hold orders prior to release for production as well as any pendin
g
shi
pments, if invoices are not paid within terms.
Dealer understands that AMYLIOR has the right to discontinue secondary discounts allowed (if any), if credit terms and/or
minimum order requirements are not me
t.
Dealer signature: Date:
Print name: Title:
FOR INTERNAL USE ONLY
Credit department approval:
Account number: Date:
Approved discount: Approved terms:
Sales approval for discount and terms: Date:
MK - TMK190530-1 June 2019 (Rev01)
SEND BY EMAIL