Dealer Application Form

Partnership Opportunities Dealer Application Dealer Locator


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Thank you for taking the time to apply online for a dealership with Control-X Medical!
We look forward to working with you soon...

Privacy note:

We value your privacy and handle your information confidentially. It is used only by Control-X Medical, Inc. for processing your dealer application and will not be shared with any third party. If for any reason the application is rejected, we delete all the information upon your request.

Fields marked with (*) are required for submission. For a successful on-line application, we suggest to fill out all applicable fields. We may contact you for further details and to provide you with more information on Control-X dealership.

1 of 4: Contact Information

	Salutation:
*	First Name:
*	Last Name:
*	Title:
*	Organization:
*	Street Address:
	Street Address 2:
*	City
*	State/Province:
*	Zip/Postal Code:
*	Country:
*	Phone:
	Fax:
	Email:
	Website URL:
	Sales Manager:	Work phone:

2 of 4: Organization Details

	Geographical area covered:
	Year company established:
	Federal Tax Id#:
	Estimated Annual Sales Revenue:
	No. of full-time employees:

3 of 4: Details of Current Activity

What type of equipment do you currently distribute and/or service?	R&F
	Radiographic Room
	Urological
	Chiropractic
	Veterinary
	Other, please specify:
Sales Ratios (%):	New Equipment:	Used Equipment:
	Processors:	Supplies:
	Service:
Please list your competitors by company name and product lines sold:
What type of equipment do you plan to distribute and service?	R&F
	Radiographic Room
	Veterinary
	Chiropractic
Manufacturers currently represented:	New X-ray equipment:
	Used X-ray equipment:

4 of 4: Credit References, Trade References Are Preferred
(Please include a fax number for each refence)

	Reference 1:	Reference 2:	Reference 3:
Company:
Address:
City:
State:
Zip:
Contact Name:
Phone:
Fax: