Dealer-Application

Humanicare International, Inc. - For all your Incontinence needs.

Humanicare International, Inc. - For all your Incontinence needs.


	If you would like to become an authorized Humanicare dealer, kindly complete and submit the following form.

Company Name:
Company Contact:
Address:
City:
State:		ZIP:
Phone:		Fax:
E-mail:

Company Tax ID #:			Year Established:
Dun & Bradstreet #:
California Medi-Cal Provider (if applicable):

Company Officers:	President/Owner:
	Purchasing Agent:
	Accounts Payable:

Bank References:	Bank Name:
	Street Address:
	City:
	State:	ZIP:
	Phone:
	Fax:
	Bank Account #:

Trade References:	1. Company Name:
(All 3 Required)	Street Address:
	City:
	State:	ZIP:
	Phone:
	Fax:
	Account #:

	2. Company Name:
	Street Address:
	City:
	State:	ZIP:
	Phone:
	Fax:
	Account #:

	3. Company Name:
	Street Address:
	City:
	State:	ZIP:
	Phone:
	Fax:
	Account #:


	The information provide is true and complete to the best of my knowledge.

Completed By:
Title:
Date: :


	Note any questions or provide additional information here:




	Terms are COD or Credit Card Charge until your credit application has been approved by Humanicare. Thank you! Please click ONCE and wait for the confirmation page.

Humanicare International, Inc.
4265 West Vernal Pike, Bloomington, IN 47404 • USA
Phone: 1-800-631-5270 Fax: 1-888-676-8080