New Supplier Application - Burkhart Dental Supply

Manufacturer Name*

Key Contact/Title*

Address

Phone

Fax

Email*

Years in business

Company Headquarters Location

Ownership

Public
Private
Employee Owned

Describe the products your company offers.*

Current Distribution Model

Are you willing to drop ship?

Yes
No

Please indicate associated fees:

What is the country of origin for most of your products?

Type of manufacturing facility:

Warehouse address:

Do you have minimum order requirements?

Yes
No

Please specify order requirements

How do you prefer to receive purchase orders?

Email
Fax
Phone

Contact information:

What is your return policy?

Do you have special markets/group pricing?

If other, please describe:

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 standard dealer price list?

Yes
No

Dealer Price List File

Max. file size: 100 MB.

Do you have a published special markets price list?

Yes
No

Special Markets 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 technical representation to support our sales team?

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

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