U.S. Dealer Application

   * Requiered
*Name of Business:
A value is required.*DBA: A value is required.
*Address:
A value is required.
*Mailing / Billing Address:
A value is required.
*Phone:
A value is required.Invalid format.		 Fax:
Invalid format.		 *Yrs In Business:
A value is required.
*Fed ID #:
A value is required.		 *NPI #:
A value is required.
*List of insurance you accept:
Website:

* Email Address:
A value is required.Invalid format.
*Type of Business:

*Principle Owner/s - Name/s, Addresses and percentage of ownership:
Name of parent company (if applicable):
*Accounts Payable Contact Name:
A value is required.*Phone: A value is required.Invalid format.

*Trade References:
(Listing 3 references is required )

A value is required.
*What regions do you serve:
*Contact Name:     A value is required.*Contact Phone: A value is required.Invalid format.

AUTHORIZATION:

The information above is given for the purpose of establishing eligibility for a credit account with Mobility Unlimited, Inc.

 

Mobility Unlimited, Inc. is hereby authorized to make any credit inquiries for approval. I certify that all of the information above is correct and that I have the authority to incur liabilities and enter into this agreement in the name of the company.
*Applicant Full Name:
 *Your Title:
 *Date:
Invalid format.mm/dd/yy
By clicking the Submit button the applicant agrees all information is true and accurate and authorizes submission.