Dealership Inquiry

Most of our products are distributed through dental Distributors. If you are a U.S. Distributor and interested in distributing our products, please fill out the Prospective Dealer Profile Form below and return it to us. If you are a qualified distributor, we will provide pricing and product information to you.

If you are an international distributor, please email us at email@applied-dental.com. We will reply to your inquiry ASAP.

Prospective Distributor Profile Form

Company Name:
Address:
City:
State/Postal code/Country:
Phone:
Fax:
E-mail Address:
Contact Person/Buyer:
Years Established:
Total # of Employees:
Re-sale Certificate #:
Geographic Area Covered:
Business References/Tel, #1:
#2:
#3:
Types of Products currently distributed:
ADI products you are interested in distributing:
Freight Choices:	UPS Fedex
Samples interested: