DEALER APPLICATION

GENERAL INFORMATION

Company Name: ______

Company Address: ______

Province/State: ______Postal/Zip Code: ______

Email Address: ______Website: ______

Billing Address: ______

Province/State: ______Postal/Zip Code: ______

Physical Plant Description: [ ] Office [ ] Showroom [ ] Warehouse [ ] Office at home

Telephone #: ( ) ______Fax #: ( ) ______Mobile #: ( ) ______

IRS #: ______SS #______

DOB: ______Contactor’s License #: ______Bond Amount: ______

COMPANY INFORMATION

President/Owner(s):1.______

2.______

Financial Officer:______

Sales Manager:______

Service Manager:______

  1. Number of years in the elevator business: ______Number of employees: ______
    Number of employees CET/CAT Certified: ______
  1. Indicate previous experience with sales and installation of our equipment or competitive equipment: ______
  1. Annual sales volume: 2007 $______2008 $______2009 Forecast $______
  1. Indicate which business segments you operate:

Commercial (%) _____ Residential (%) _____ Service/Maintenance: ______

  1. Territory normally covered: ______
  1. Indicate which Inclinator products you are interested in:

ELEVATORS: [ ] Cable [ ] Hydraulic [ ] MRL Chain [ ] MRL Traction

DUMBWAITERS: [ ] Dumbwaiter (commercial & residential) [ ] Homewaiter (residential)

WHEELCHAIR LIFTS: [ ] SpectraLift (fiberglass) [ ] VL (steel)

STAIR LIFTS: [ ] Stair Package Lift

  1. Indicate the forms of advertising which you use:

[ ] Yellow Pages[ ] Direct Contact with Architects/Builders

[ ] Website[ ]_ Direct Mailing

[ ] Referrals[ ] AIA Architects & Builders

[ ] Tradeshows[ ] Internet (Google.com, Bluebook.com, Yellowpages.com, etc.)

[ ] Magazines (name) ______

______

[ ] Other (list) ______

8.List any manufacturers of accessibility products that you currently represent, or have represented in the past.

Company NameNumber of Years

1. ______

2. ______

3. ______

9.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 Company of America)

______

10.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: ______Telephone #: ( ) ______

Amount of LIABILITY INSURANCE COVERAGE: $ ______

CREDIT REFERENCES

Name City/State Phone NumberFax Number

1. ______(___)______(___)______

2. ______(___)______(___)______

3. ______(___)______(___)______

4. ______(___)______(___)______

BANKING INFORMATION

Name: ______Federal ID #: ______

Address: ______

Contracting License #: ______Workers Comp #: ______

Bank Contact: ______Title: ______

Contact Phone Number: ( ) ______Fax Number: ( ) ______

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.

TERMS AND CONDITIONS

I/we certify that the above information is correct and complete and further understand that Inclinator Company of America will rely on this information for the extension of credit. Dealer authorizes INCOA 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 aggress to supply such additional information as may be required by INCOA to warrant the future extension of credit or enable INCOA to perfect liens or to recover upon any bond issued. 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.

______

Authorized Applicant SignatureTitleDate

______

Name (Please Print)