B2B Portal Access Inquiry Form

Legal Company Name*

DBA (Doing Business As)*

Website*

Name*

First Last

Title*

Email*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

How did you hear about the B2B portal?*

Are you currently buying OMRON Healthcare products?*

If "Yes," where do you purchase your OMRON Healthcare products (list of all sources)?*

Please describe your business model; how will you distribute our products?*

What category(s) of OMRON Healthcare products will you purchase?*

How will you use our products?*

Please provide any other additional information you believe we need to know about your business.

As the person submitting this inquiry, you represent and warrant that you have the authority to provide the information required and to submit this application. If you do not have the appropriate authority and/or cannot provide the required information, please exit this inquiry form now. If you have the appropriate authority and can provide the required information, please click on the check box below and click on the "I agree" button.*

Yes, I have the appropriate authority to submit this inquiry and certify that the answers provided are true and accurate.

OMRON does not give one time authorizations or exceptions to the authorization criteria. Incomplete applications or applications missing requested documentation will not be reviewed. Completion and return of the application form does not constitute acceptance by OMRON or approval as an Authorized Retailer. OMRON reserves the right at its sole discretion to deny authorization for any reason and re-evaluate each partner at their discretion. Questions regarding the Authorized Retailer Program may be directed to [email protected].

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