To become a Wear Ease Retailer:



Dealer Application
Name of Business (*)
Please let us know your name.
Contact Name: First & Last Name (*)
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Job Title (*)
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Phone # (*)
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Email (*)
Please let us know your email address.
Fax #
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Ship to Address
Street Address (*)
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City (*)
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State (*)
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Zip Code (*)
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Bill to Name & Address (leave blank if same as shipping address)
Accounts Payable First & Last Name (*)
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Accounts Payable Phone # (*)
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Accounts Payable Email (*)
Please let us know your email address.
Accounts Payable Fax #
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Street Address
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City
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State
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Zip Code
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Company Information
Federal ID# (*)
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Resale Certificate #
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Line of Business (ex: DME, shop, hospital, O&P) (*)
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Date Business Began (*)
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Parent Company (if applicable)
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Type of Business
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Yearly Sales Volume (*)
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Expected monthly credit requirement from Wear Ease, Inc. (*)
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What credit terms would you like? (*)
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Comments
Please let us know your message.

Terms and Conditions Signature Page

I have read, agree and signed the Wear Ease Terms and Conditions page and will email to mari@wearease.com or fax it to 208-445-0957 (*)
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