Dealership Inquiry

Most of our products are available for distribution through dental dealers. If you are a US Distributor and
interested in distributing our products, please fill out the Prospective Dealer Profile Form below fax it back
to us at 408-427-9009. If you are a qualified distributor, we will provide pricing and product information
to you.
We are currently seeking business partners for overseas markets. If you are an International Distributor
interested in our products, please email us at email@applied-dental.com. We will be happy to discuss
available opportunities with you.

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: