Dealer/Contractor Application
Adapy is the manufacturer of the Adapy Smart Mobility System, and various smart technologies and the applicant desires to resell (and/or) install the adapy product(s).

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

*Legal Entity
CorporationLLCPartnershipSole Proprietor

*Your Business Name

*Your Business Website

*Effective Date

*Your First & Last Name

*Your Title

*Your Email

*Phone Number

*Your Address

*Your City

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

*Your Country

*What brands of products do you sell
BrunoBraunAbilityHarmarRiconAdapt SolutionsAmeriglideOther

*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

You agree to the following:
Your signature will be applied to the below documents acknowledging your acceptance.

Adapy's current installation fee schedule (View Document)
Adapy's Adherence Policy (View Document)
Dealer/Installer Agreement (View Document)
HIPAA Compliance Toolkit for Installers (View Document)
Adapy's Brand Standards (View Document)
Adapy's official Limited Warranty Statement (View Document)
Adapy's official Installation guideline (View Document)
Exhibit A Territory Designation (View Document)

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

By proceeding, the dealer acknowledges and agrees to have read and fully understood the Dealer Agreement, as outlined in the document located at [Insert Link Here]. This agreement is integral to the continuation of our partnership and must be adhered to in its entirety.

Sign Here (Use Mousepad or Active Mobile/Tablet Screen)