| Company Name (Bill to) | Company Name (Ship to) | |||||||||||
| Address | Address | |||||||||||
| City | State | Zip | City | State | Zip | |||||||
| Contact Name | Contact Email | Contact Phone | Federal Tax ID | |||||||||
| Credit Line Requestsed | Company Website | Buying Group Affiliation | Member Number | |||||||||
| Describe your business, including experience selling wheeling wheelchair ramps. | ||||||||||||
| Trade References (You can attach this information as a separate sheet) | ||||||||||||
| Company Name | Contact | Phone | Fax | |||||||||
| Address | City | State | Zip | |||||||||
| Company Name | Contact | Phone | Fax | |||||||||
| Address | City | State | Zip | |||||||||
| Company Name | Contact | Phone | Fax | |||||||||
| Address | City | State | Zip | |||||||||
| Finance and Banking Information | ||||||||||||
| Name of Bank | Account Number | Type of Account | ||||||||||
| Address | City | State | Zip | |||||||||
| Phone | Fax | |||||||||||
| Terms & Conditions | ||||||||||||
| 1 | Payments can be made by prepayment, credit card or via credit upon receipt of credit line approval | |||||||||||
| 2 | Payment is due 15 days from the date of shipment of purchase. | |||||||||||
| 3 | Accounts past due over 31 days are subject to a 1-1/2% monthly service charge. | |||||||||||
| 4 | All accounts delinquent over 60 days will be placed on a COD basis. | |||||||||||
| 5 | All freight is FOB Traverse City, Michigan. Let us know if you would like to make your own freight arrangements and be billed direct by your shipper. | |||||||||||
| 6 | All returned or refused delivery items are subject to a 15% handling and restocking charge, plus freight both ways. | |||||||||||
| 7 | A handling fee of $30 will be charged on all returned checks. | |||||||||||
| 8 | The dealer should have an active website and establish a link to the Add-a-Ramp website that says, "We are an authorized Add-a-Ramp dealer for more information on wheelchair ramps go to www.add-a-ramp.com." | |||||||||||
| Terms & Conditions (Continued) | ||||||||||||
| 9 | The dealer must use a licensed or well trained and insured installer or contractor to install Add-a-Ramp. | |||||||||||
| 10 | The dealer is responsible to install the ramp per Add-a-Ramp’s installation instructions, to local building code specifications and to obtain building permits if required. | |||||||||||
| 11 | Dealer shall hold Add-a-Ramp (Beta Quest LLC) harmless from all costs, expenses, damages, claims and all liabilities in the event that the dealer does not install Add-a-Ramp pursuant to instructions. | |||||||||||
| 12 | Unless otherwise agreed to, the Add-a-Ramp dealership is not-exclusive | |||||||||||
| Due to the tightening of regulations in the release of credit information, lending institutions are now requiring written authorization from their depositor's for the release of information. Please complete all the information on this form and fax this application, complete in its entirety to Beta Quest LLC (DBA - Add-a-Ramp) 616-475-5076 or email to terry@add-a-ramp.com. Thank you! | ||||||||||||
| I authorize the institution specified above to respond fully to the request of Beta Quest LLC (DBA - Add-a-Ramp) for credit and banking experience for the accounts described above. | ||||||||||||
| Today's date | ||||||||||||
| Name of Company | ||||||||||||
| Owner/Officer (printed) | Title | |||||||||||
| Signiture | ||||||||||||
| For Add-a-Ramp's use only | ||||||||||||
| Custome ID Number | ||||||||||||
| Credit Limit | Date | Terms | ||||||||||
| Comments | ||||||||||||