Current Authorized Internet Reseller Inquiry Form Legal Company Name*DBA (Doing Business As)*Corporate Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Website* Applicant's Name* First Last Applicant's Email* Applicant's Title*Applicant's Phone*Where do you purchase your Omron products? If from a distributor, which one?*Please describe your business model; who do you sell to and what do you sell?*What type of Reseller do you consider yourself?*Etailer/Ecommerce/OnlineDistributorBrick & MortarCombinationOtherDo you sell on one or more more the following marketplaces?*Amazon.comeBay.comJet.comWalmart.comNoneOtherIf yes, please list all online store web addresses/URLs (including marketplace stores).What category(s) of Omron products do you sell?*Home Blood Pressure MonitorsElectrotherapy TENSFitness DevicesProfessional Blood Pressure MonitorsRespiratoryPlease describe your store(s) location.How many retail locations do you operate?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. I understand that failure to comply with all of the terms in Omron’s Authorized Internet Reseller Policy will result in suspension or termination of my account. Omron does not give one time authorizations or exceptions to the authorization criteria below. Incomplete applications or applications missing requested documentation will not be reviewed. Completion and return of the inquiry form does not constitute acceptance. Omron reserves the right at its sole discretion to deny authorization for any reason and re-evaluate each partner at their discretion.