Online Dealer Application

General Information
Person Completing Form*
Company Name*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Physical Plant Description
Phone **
Cell Phone
Email*
Website
Address
Street Address City State / Province / Region ZIP / Postal Code
Federal ID #
Contractor's License #
Worker's Comp #
Bond Amount $
Company Information
President/Owner Name
Financial Officer
Sales Manager
Service Manager
Number of years in the elevator business
Number of Employees
Number of employees CET/CAT Certified
Indicate previous experience with sales and installation of our equipment or competitive equipment
Annual sales volume (2 Yrs Ago) $
Annual sales volume (Last Year) $
Annual sales volume (Forecast This Year) $
Indicate which business segments you operate:
Commercial (%)
Residential (%)
Service/Maintenance (%)
Territory normally covered
Below are the four Inclinator products. For those you are interested in carrying, indicate your expected 1st and 2nd year purchases.
Elevette Cable Drum Home Elevators (FIRST YEAR)
Elevette Cable Drum Home Elevators (SECOND YEAR)
Elevette Hydraulic Home Elevators (FIRST YEAR)
Elevette Hydraulic Home Elevators (SECOND YEAR)
Commercial/Residential Dumbwaiters (FIRST YEAR)
Commercial/Residential Dumbwaiters (SECOND YEAR)
Vertical Platform Wheelchair Lifts (FIRST YEAR)
Vertical Platform Wheelchair Lifts (SECOND YEAR)
Enter the annual advertising spending amounts ($)
Yellow Pages
Direct Contact with Architects/Builders
Website
Direct Mailing
Referrals
AIA - Architects/Builders
Tradeshows
Internet (Google, Bluebook, Yellowpages, etc)
Magazines (include Name)
Radio/TV (include Name)
Other
List manufacturers of accessibility products that you have represented or currently represent
Company Name 1
Number of Years
Products
Company Name 2
Number of Years
Products
Company Name 3
Number of Years
Products
Indicate, in detail, the territory that you propose to cover with sales and service of the Inclinator product line. (Final assessment of territorial boundaries is at the sole discretion of Inclinator.)
North
South
East
West
Supply the name and address of your liability insurance carrier. A copy of your current Certificate of Insurance – with dollar amounts – must be submitted with this application.
Insurance Company
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone
Amount of LIABILITY INSURANCE COVERAGE $
Certificate of Insurance
Credit References
Company 1*
Contact*
City
Province/State
Phone
Email
Company 2*
Contact*
City
Province/State
Phone
Email
Company 3*
Contact*
City
Province/State
Phone
Email
Banking Information
Bank Name
Federal ID #
Address
Street Address City State / Province / Region ZIP / Postal Code
Contact at Bank
Phone
Email
I, the undersigned, hereby grant permission for the above named Bank and trade References to release information relative to our account with them for the purpose of obtaining credit with Inclinator Company of America.*
- Yes, I agree.
Terms & Conditions
I/we certify that the above information is correct and complete and further understand that Inclinator Company of America (ICOA) will rely on this information for the extension of credit. Dealer authorizes ICOA at any time and from time to time to obtain Credit Reports on Dealer or any individuals listed above or to obtain credit and funding information from other persons or entities listed above. Dealer further agrees to supply such additional information as may be required by ICOA; such as: financial statements and tax returns to warrant the future extension of credit or enable ICOA to perfect liens or to recover upon any bond issued. In addition ICOA may require a Personal Guaranty for extension of an open credit line depending on the strength of other information provided. Dealer agrees to pay all costs incurred in collection of past due amounts, including attorney’s fees in the amount of 1/3 of the total balance due from Dealer in the event this account is placed with an attorney for collection, whether suit is filed thereon or not. If you have questions or problems with this Dealer Application Online Form, please call Inclinator’s Brad Rose at 717-939-8420 x226 or toll-free at 1-800-343-9007 x226.
Signature
As the Authorized Officer, I agree that by submitting this application, I am electronically signing the application and agreeing with the above Terms and Conditions.
Name*
First Last
Title*
Date*
Date Format: MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

Online Dealer Application

General Information

Company Information

Credit References

Banking Information

Terms & Conditions

Signature

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