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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).

*Would you like to become an Adapy Dealer?
YesNo

*Effective Date

*First & Last Name

*Title

*Email

*Business Name

*Business Website

*Business Address

*City

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

*Country

*What brands of products do you sell
BrunoBraunAbilityHarmarRiconAdapt SolutionsAmeriglideOther

*How many installations of adaptive equipment do you do a month?
1-55-1010-1515-2020-2525-3030-5050+

*How many installations are for US Military Veterans?
1-2%3-5%5-10%More than 10%

*How many of these installations are paid for by Workforce Services/Vocational Rehab?
None10%20%30%40%50%60%70%80%90%100%

Acknowledge & Agree to the below documents by adding a checkmark next to each item

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 above. This agreement is integral to the continuation of our partnership and must be adhered to in its entirety.

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