Owner / Manager Full Name

Business Name *

Address

Street Address

City

State

Country

Postal Code

Business Website

Years in Business *

Phone *

Email *

Type of Business *

Type of Business

Physical Retail Location *

Physical Retail Location

Storefront Photo

Do you currently sell adjustable beds, lift chairs, or mobility equipment? *

sell_adjustables

Approximate Retail Square Footage *

Retail Square Footage

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By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Average Monthly Customer Foot Traffic *

Monthly Foot Traffic

What brands of beds or mobility products do you currently carry? *

Brands Carried

Dropship or Stock Inventory *

Dropship only

Stock inventory

Both

Inventory Preference

In-store demo unit? *

In-Store Demo

Agree to follow MAP policy? *

MAP Policy Agreement

Estimated Beds Sold per Month *

Beds per Month

Agree not to resell exclusively online?

Online Resell Agreement

How soon would you like to get started? *

Start Timeframe