DEALER APPLICATION

Dealer Application

Kayser Betten US

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U.S. Dealer Application Form

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U.S. Dealer Application

Name of Business*

DBA

Federal ID #

NPI #*

Address*

Mailing/Billing Address

Phone #

Fax #

Website

Number of Years in Business

Type of Business

Principal Owner(s)

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Accounts Payable Contact

Name

Phone #

Regions You Serve

Insurances You Accept

Trade References

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Bank Information

Name

Account Number

Phone Number

Bank Contact Name

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AUTHORIZATION:

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The information above is given for the purpose of establishing eligibility for a credit account with Mobility Unlimited Inc. DBA KayserBetten US

Mobility Unlimited, Inc. DBA KayserBetten US is hereby authorized to make any credit inquiries for approval. I certify that all the information above is correct and that I have the authority to incur liabilities and enter into this agreement in the name of the company.

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Main Phone: (877) 711-9447

Mobile Phone: (610) 360-1374

Alternate Phone: (610) 433-8797

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Mon - Fri: 9:00 am - 5:00 pm
Sat - Sun: Closed

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