Retailer Information Form

Retailer Information Form

Please note that ALL information below is required to be filled out in order to open an account with Prestige Medical.

Retailer Name:   Address 1:
Retailers License No:   Address 2:
Date Established:  /   /    City:
Is this a Store Front?        State:  Zip: 
Note: Must be filled out if country is anything other than USA  
Freight Forward Company:   
Please be ready to provide a valid Retailer License and ID in order to open an account.
First Name:   Email Address:
Last Name:   Phone Number:
Your Title:   Fax Number:

What type of products do you currently carry?
(Please check all that apply)

  What products do you want to purchase from us?
(Please check all that apply)


How did you hear about us?   Additional notes or questions.

This is NOT a credit application. Filling out this form does NOT guarantee that you will be able to purchase products from us. We will contact you regarding your inquiry. Thank you.