Dealer Application Form

Interested in becoming a dealer for Living Spinal?

Here are a few of the benefits of signing up:

• It's FREE to sign up
• Capture NEW customers 
• Ability to make more MONEY

Best of all, you receive local referrals from our ongoing nationwide marketing campaigns!

To get started, please submit the form below and a member of our dealer team will contact you at the phone number provided.

First Name *

Last Name *

Manager Name *

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Best time to call Please select one 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM

Email *

Are you a Segway dealer *

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Are you a DME retailer? *

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Are you a different type of dealer?

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Website *

Business Name *

EIN Number *

Business Street Address *

Business City *

Business State *

Business Postal Code *

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