*Date

*Company Name

*Legal Entity
CorporationLLCPartnershipSole Proprietor

*This location would like to become a (check all that apply)
DealerInstaller

*What brands of products do you sell
BrunoBraunAbilityHarmarRiconAdapt SolutionsAmeriglideOther

*Dealer/Installer Mailing Address:*

*City

*State
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

*Zip

*Your First and Last Name

*Title

*Phone Number

*Your Email

*Website

*Can you provide a Certificate of Insurance:
YesNoNot Sure

*Can you provide a W-9:
YesNo

*Number of employees at this location
1-55-1010-1515+

*How many adaptive equipment installations (adaptive/mobility) does this location do per month (estimated)
1-55-1010-1515-2020-2525-3030-5050+

*How many of these adaptive equipment installations (adaptive/mobility) are for US Military Veterans (estimated)
1-2%3-5%5-10%More than 10%

*How many of these adaptive equipment installations (adaptive/mobility) are processed for payment through Workforce Services?
None10%20%30%40%50%60%70%80%90%100%

*How many of these adaptive equipment installations (adaptive/mobility) are processed for payment through Veterans Administration?
None10%20%30%40%50%60%70%80%90%100%

*How many of these adaptive equipment installations (adaptive/mobility) are processed for payment through a GSA Contract?
None10%20%30%40%50%60%70%80%90%100%

*How many of these adaptive equipment installations (adaptive/mobility) are processed for payment through Vocational Rehab?
None10%20%30%40%50%60%70%80%90%100%

*How many of these adaptive equipment installations (adaptive/mobility) are processed for payment through Medicare?
None10%20%30%40%50%60%70%80%90%100%

*How many of these adaptive equipment installations (adaptive/mobility) are processed for payment through Medicaid?
None10%20%30%40%50%60%70%80%90%100%

*What percentage of your past customers return to your location for annual checkup's repairs, etc.?
10%20%30%40%50%60%70%80%90%100%

*What percentage of your past customers do you continue to market to after the initial installation or sale?
None10%20%30%40%50%60%70%80%90%100%

*How long have you been in business?
1 Year2-5 Years5-7 Years7-10 Years10-15 Years15+ Years

*How many locations do you have?

1234567891010-1515-2020-3030-5050+

*What is your average markup on add-on's and upsell items?
None10%20%30%40%50%60%70%80%90%100%

*Would you be interested in a Kiosk placed in your lobby with an Ipad that helps introduce Adapy to your customers?
YesNoMaybe

*Would you be interested in receiving leads from the Adapy's website for people interested in our products and services?
YesNoMaybe

Background
Adapy is the manufacturer of the Adapy Smart Mobility System, and the Dealer desires to resell the aforementioned product(s).

Terms and Conditions
1. Appointment: Adapy appoints the Dealer as a non-exclusive authorized reseller of its products. The Dealer agrees to promote and sell these products within the agreed territory.
2. Product Use: The Dealer shall use its best efforts to market, promote, and sell Adapy's products in a professional and ethical manner.
3. Pricing: Adapy will provide the Dealer with a wholesale price list. The Dealer agrees not to sell the products below the minimum advertised price (MAP) set by Adapy.
4. Orders and Delivery: All orders placed by the Dealer shall be subject to acceptance by Adapy. Adapy shall make commercially reasonable efforts to fulfill orders promptly. Delivery terms and conditions shall be as agreed upon separately in writing.
5. Payment: Payment terms will be specified in each individual order. Adapy reserves the right to modify terms based on creditworthiness or other considerations.
6. Marketing and Promotion: The Dealer agrees to adhere to Adapy's marketing guidelines and brand image in all promotional materials, advertising, and sales efforts.
7. Intellectual Property: The Dealer acknowledges that all intellectual property rights related to the products remain with Adapy. The Dealer shall not claim ownership or attempt to register any of Adapy's intellectual property.
8. Confidentiality: Both parties agree to keep all confidential information obtained during the course of this agreement confidential and shall not disclose it to any third party without prior written consent.
9. Termination: Either party may terminate this Agreement with written notice if the other party breaches any material term of this Agreement.
10. Governing Law: This Agreement shall be governed by and construed in accordance with the laws of the State of Utah.

IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the date first above written.

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