Purchasing Agreement: Fake Inc.

PRACTICE INFORMATION:
Practice Name (required)

Name of Primary Dentist (required)

Name of Employee Ordering Supplies (required)

Email of Employee Ordering Supplies (required)

Practice Phone# (required)

State (required)

Do you currently purchase with Fake inc.? (required)
—Please choose an option—YESNO

I would like: (required)
—Please choose an option—All my locations included into a single account with this VendorAll my locations to have a separate account with this Vendor.

Cooperative Account# (Found on Invoice. Optional)

Notes:

TERMS AND CONDITIONS OF PARTICIPATION
To qualify for the Dental Cooperative negotiated volume discount pricing with our vendor partner, participants must meet the following criteria:
• Participants must be a current member of the Dental Cooperative in good standing.
• All associated items subject to discount must be purchased through the identified sales channels as specific above.
• Discount pricing structure begins only after agreement has been received and processed by the Dental Cooperative and vendor partner.
• Upon termination from the Dental Cooperative, Member will no longer have access to discount pricing defined in the terms.
• Signing this document permits Ormco to transition your current account to the Dental Cooperative group account.
• Additional program details and terms are available on Member Services.
I agree to the Terms and Condition of Participation in this Agreement.

Name of Authorized Agent (required)

Date Agreement Signed MM/DD/YYYY (required)

Once submitted, the Agreement will be sent to our the associated vendor partner for a rep assignment and flagging in their system. Confirmation will be emailed to you when your vendor rep has been assigned.