Become a Distributor | Dale Medical

Interested in becoming a distributor?

Please fill out this brief form and a member of our team will get back to you shortly.

Name*
First Last
Date*
Date Format: MM slash DD slash YYYY
Email*
Contract #
THIS FORM MUST BE COMPLETLY FILLED OUT IN ORDER TO PROCESS YOUR APPLICATION

Legal Name of Business
Legal Name of Business*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Fax*
Years in Business*
# of Sales Reps*
Geographical Areas Served*
Branches*
Estimated Annual Revenue*

Owners, Principal Officers, ETC.
Name*
First Last
Title*
Name
First Last
Title
Name
First Last
Title
Name
First Last
Title

Credit References
Principal Bank Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Name*
First Last

Trade References
Name*
First Last
Address*
City State / Province / Region ZIP / Postal Code
Phone*
Fax
Name
First Last
Address
City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Name
First Last
Address
City State / Province / Region ZIP / Postal Code Country
Phone
Fax

WHAT OTHER LINES DOES YOUR ACCOUNT DISTRIBUTE:
Sales Breakdown: This Section Needs to Be Completed to Process our Application
% In Hospital Sales*
% In Laboratory Sales*
% In Physician Sales*
% In International Sale*
% In Home Health Sales*
% In Retail Sales*
Minimum order of $1000.00 required, fax this filled form to 508-695-6587 for distribution consideration.
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