Dealer Registration Form

XMEDEX DISTRIBUTOR APPLICATION

Please provide all required details below to qualify your business with us. If your company qualifies to become a dealer, an XMEDEX representative will be in contact with you to discuss further opportunities. Thank you for your interest in XMEDEX products.
LEGAL DISCLAIMER

The undersigned applicant ("Applicant") submits this Application to XMEDEX Pty Ltd (ABN 48 590 596 237). All private/non-public information submitted by the applicant shall be held in complete confidence by XMEDEX TECHNOLOGIES GROUP.

APPLICANT AGREEMENT:

* The information provided by the Applicant is true & correct to the best of their knowledge.

* XMEDEX Pty Ltd may, in reviewing this Application, investigate and evaluate the credit worthiness, general reputation, character, background and experience of Applicant. Applicant expressly requests and authorizes any individual, partnership, corporation or other entity to provide XMEDEX Pty Ltd. and its employees and agents (including independent investigative agents) with any and all information that may be requested of them in connection with the review of this Application.

* This Application does not bind Applicant to accept, nor does it bind XMEDEX Pty Ltd. in any way to offer, an XMEDEX Distributor Agreement to Applicant. Any investments, expenditures, agreements, and other acts or omissions made by Applicant in anticipation of such a Distributor Agreement or in reliance upon this application are made at Applicant's sole risk and responsibility and do not obligate XMEDEX Pty Ltd or any of its employees or agents in any way.

* Any material misrepresentation or omission, intentional or unintentional, in the information supplied by Applicant to XMEDEX Pty Ltd shall constitute grounds for XMEDEX Pty Ltd to immediately terminate any Distributor Agreement that may be entered into by XMEDEX Pty Ltd with Applicant.
START APPLICATION
Authorized Contact Representative*

First NameLast Name
Legal Business Name*
Business Company Number (ABN)*
Business Name / Trade Name / DBA*
Contact Number*

Area CodePhone Number
E-mail*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Type of Business*
Please provide a short description about your company.*
How did you hear about XMEDEX ?*
If Other was selected above, please specify here:
Please describe your current interest level in becoming an XMEDEX Dealer.*

Looking to start selling in in the next 3 monthsLooking to start in 6 monthsLooking to start in 12 monthsCurrently just researching for dealer opportunitiesReady to get started immediately
How many years have you been in business?*
What is your approximate annual sales volume?*
How many sales people do you have on your team?*
Location where Applicant proposes to sell XMEDEX products?*
Detailed description of plan for marketing & selling XMEDEX products*
Trade or Industry references we may contact
Additional Information (Optional)
Should be Empty:

XMEDEX DISTRIBUTOR APPLICATION