New Suppliers

Home > Manufacturer Partners > New Equipment Partner Application

New Equipment Partner Application

If you’d like to partner with Burkhart as an equipment supplier, please fill out the New Equipment Partner Application form below.

Manufacturer Name*
Key Contact/Title
Address
Phone
Fax
Email
Years in business
U.S. Based Company?
List Location
Ownership
Describe the products your company offers.*
Current Distribution Model
Are you willing to drop ship? Y/N Fees?
Where are these products manufactured?
Type of manufacturing facility:
Location of warehouse
Do you have minimum order requirements?
- Yes
- No
Please specify order requirements
How do you prefer to receive Purchase Orders?
Are you willing to accept returns for credit?
- Yes
- No
What is your return policy?
Do you offer special pricing?
What are your special pricing criteria for eligibility?
Current authorized dealers of your dental products
Do you have a standard distributor agreement?
- Yes
- No
Distributor Agreement File
Max. file size: 100 MB.
Do you have a Published Dealer Price List?
- Yes
- No
Dealer Price List File
Max. file size: 100 MB.
Payment terms/early payment discount structure
What rebate/discount opportunities are available?
We have a variety of marketing opportunities to promote your products. Do you have an initial budget to advertise with Burkhart?
- Yes
- No
Amount:
Will you offer Spiffs or Incentives for Burkhart Sales Associates?
- Yes
- No
Who is the Marketing contact at your company?
Do you have sales representation in the markets we support?
- Yes
- No
Product evaluations may be required. Will you provide samples of your product(s)?
- Yes
- No
Can you provide proof of product liability insurance?
- Yes
- No
DUNS Number
GLN Number
DEA Number
Submitted by:
Date
MM slash DD slash YYYY

Δ

About Us

Our Culture
Careers
Contact
Manufacturer Partners
Media Opportunities

Suppliers & Equipment

Shop Supplies
Private Label Products
Equipment & Technology
Catalogs

Services

Service & Repair
Business Solutions
Office Design
Practice Consulting
Supply Savings Guarantee
Financing
Payment Options

Quick Links

My Burkhart Billpay
My Account
Resources

Customer Service: 1.800.562.8176

Terms of Use
Privacy Policy
Manufacturer Partners
Media Opportunities
Log In

Search

Phoenix Dental Office Bus Tour April 19th

New Suppliers

New Equipment Partner Application