Reseller Application

* Required Information
Company Name*:
Address 1*:
Address 2:
City*:
State*:
Zip*:
Country*:
Phone*:
Fax:
Website Address*:
Email*:
Contact Person*:
Date Company Started*:
Number of Employees*:
Annual Sales*:
State Reseller License Number*:
What prompted you to contact us?
What is the main focus of your business?
Please list the companies you represent:
How do you intend to market our product?
Do you print a catalog? (If yes, please mail us one.)
What geographical areas do you cover?
Are you an approved DME / Medicaid provider? (If yes, in which states?)
Which conferences do you attend?
Please list three trade references (contact name, company name, address, phone, website, and email address):

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Mayer-Johnson LLC, PO Box 1579, Solana Beach, CA 92075. Phone: 800.588.4548. Fax: 858.550.0449