Authorized Internet Retailer Inquiry Form

Legal Company Name*

DBA (Doing Business As)*

Company Website

Name*

First Last

Title*

Email*

Phone*

Corporate 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; who do you sell to and what do you sell?*

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

Where do you intend to sell OMRON Healthcare products?*

What type of Reseller do you consider yourself?*

If you intend to sell OMRON Healthcare products online, please identify all websites where you wish to sell products. Please make sure to include ALL business websites as well as any marketplaces.

Are you interested in applying for permission to sell on one or more of the following online marketplaces?*

Please note that acceptance as an Authorized Retailer does not constitute authorization to sell on online marketplaces. The company’s rules regarding online marketplace sales are set forth in the Authorized Retailer Policy.

If you selected "Other", identify any other online marketplaces.*

Please describe your store location(s).

How many retail locations do you operate?

Do you store or intend to store your inventory of OMRON Healthcare products at a location other than the Company Address identified above?*

Do you use or intend to use any third party fulfillment service to store inventory or fulfill orders of OMRON Healthcare products?*

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

If you answer yes to any of the following three questions, please describe the matters in detail.

Business Information

Entity Type*

State of Incorporation*

Year Incorporated*

Company EIN*

Resale Certificate Number and State*

Company DUNS

Has the Company ever declared bankruptcy?*

Has any company in which any of the Company’s principals have an ownership interest ever declared bankruptcy?*

Are there any pending lawsuits involving the Company?*

As the person submitting this application, 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 application 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 application and certify that the answers provided are true and accurate. If I am approved as an Authorized Retailer, I agree to comply with all terms in the OMRON Authorized Retailer Policy. I understand that failure to comply with all of the terms in the OMRON Authorized Retailer Policy will result in suspension or termination of my account.

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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