*All Fields are required.
Company's Legal Name
Company's DBA / Trade Names (if any) If none, please write none
Company Address
Company Address 2
Company City
Company State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Company Zip Code
Company Email Address
Company Phone Number Please format as XXX-XXX-XXXX
Entity Type Corporation Limited Liability Company Limited Partnership Partnership Sole Partnership Other
Entity Type (if other)
State of Incorporation / Organization AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
EIN / TAX ID Please insert your nine-digit number in this format: XX-XXXXXXX.
Primary Contact's First Name
Primary Contact's Last Name
Primary Contact's Position at Company
Primary Contact's Email Address
Primary Contact's Phone Number (work) Please format at XXX-XXX-XXXX
Do you sell or intend to sell PDI products at any brick-and-mortar locations Yes No
Please identify the physical address for each brick-and-mortar location where you sell or intend to sell PDI products Please include name/street address, city/state/zip code for each location
Please identify the URL for each website where you intend to sell PDI products Please review the restrictions on online sales in the Authorized Reseller Policy carefully. Please note that you are only permitted to sell the Products on “Permissible Public Websites,” as defined in the Authorized Reseller Policy. Consent to sell PDI products on online marketplaces is not granted through this website registration process.
From which authorized distributor(s) do you purchase PDI products? Cardinal Concordance Henry Schein McKesson Medline NDC/MedPlus Owens and Minor Other
If "Other", please identify
Do you store or intend to store your inventory of PDI products at a location other than the company address identified above? Yes No
Please provide the address for all locations where your inventory if stored or will be stored. Please include name/street address, city/state/zip code for each location
Do you intend to use any third-party fulfillment service (including drop-shipment by an authorized distributor) to fulfill orders for PDI products placed through the website(s) identified above? Yes No
Please identify the name of the fulfillment service and describe the services provided
By checking the box, I agree, on behalf of Reseller, as follows: Acknowledges and agrees that it will abide by the Professional Disposables International, Inc. Authorized Reseller Policy for the United States .Understands that it is strictly prohibited from using PDI’s brands, names, logos, trademarks, service marks, trade dress, copyrights, and other intellectual property in any way other than as granted in the A.R. Policy without PDI's prior written consentAffirms that the information provided in this Form is true, accurate, and current. You must check each box before submitting the form.
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Questions? Contact Us at authorized@pdihc.com