Dealer Application :

Company Name : ______________________________________________________

Company Website :_____________________________________________________

Contact Name :________________________________________________________

Contact Direct # :_____________________ Contact Cell # :____________________

Contact Email : ___________________________

Billing Address : _______________________________________________________

City : __________________ STATE : __________________ ZIP : ________________

Business Phone # ____________________________

Type of Business :____________________________

Sales Tax ID# ________________________________

FED Tax ID# _________________________________

Do you have a retail store ? ____________________

Do you plan to have a unit in your retail store ? _____________________________

How many Walk in Tubs do you project to sell a month ? ______________________

What products do you currently sell ? _____________________________________

Will your company providing install services ? _______________________________

How will we send you leads ? ____________________________________________

References

1. Company Name _____________________________________________ Address ____________________________________________________ Email Address _______________________________________________ Phone # ____________________

2. Company Name _____________________________________________ Address ____________________________________________________ Email Address _______________________________________________ Phone # ____________________

3. Company Name ______________________________________________ Address _____________________________________________________ Email Address ________________________________________________ Phone # ____________________ ** Please Send Before and After Pictures of Walk in Tub Installations to Dealer@MobilityBathworks.com ** Our firm and none of it’s officers, principals, partners or owners have file bankruptcy within the last ten years, nor do any of those parties have federal, state, county or municipal tax liens or civil suits or judgments filed against them within the last six years, Indicate ___Yes or ___ No. If yes please attach a separate sheet of paper with full details. We further agree that in the event that the creditor is forced to take legal action against our firm, its owner, principals, officers, guarantors, or myself, to reimburse the creditor for all collection agencys’s, attorney’s, marshal’s and sheriff’s commissions and fees, process server or investigation costs, interest and all court costs as the court may adjudge.

Signature of Authorized Representative

X_______________________________________________ Date: _______________

Print Name Here

________________________________________________ Date: _______________