Online Dealer Application

  • General Information

  • Company Information

  • Indicate which business segments you operate:
  • Below are the four Inclinator products. For those you are interested in carrying, indicate your expected 1st and 2nd year purchases.
  • Enter the annual advertising spending amounts ($)
  • List manufacturers of accessibility products that you have represented or currently represent
  • Indicate, in detail, the territory that you propose to cover with sales and service of the Inclinator product line. (Final assessment of territorial boundaries is at the sole discretion of Inclinator.)
  • Supply the name and address of your liability insurance carrier. A copy of your current Certificate of Insurance – with dollar amounts – must be submitted with this application.
  • Credit References

  • Banking Information

  • Terms & Conditions

    I/we certify that the above information is correct and complete and further understand that Inclinator Company of America (ICOA) will rely on this information for the extension of credit. Dealer authorizes ICOA at any time and from time to time to obtain Credit Reports on Dealer or any individuals listed above or to obtain credit and funding information from other persons or entities listed above. Dealer further agrees to supply such additional information as may be required by ICOA; such as: financial statements and tax returns to warrant the future extension of credit or enable ICOA to perfect liens or to recover upon any bond issued. In addition ICOA may require a Personal Guaranty for extension of an open credit line depending on the strength of other information provided. Dealer agrees to pay all costs incurred in collection of past due amounts, including attorney’s fees in the amount of 1/3 of the total balance due from Dealer in the event this account is placed with an attorney for collection, whether suit is filed thereon or not. If you have questions or problems with this Dealer Application Online Form, please call Inclinator’s Brad Rose at 717-939-8420 x226 or toll-free at 1-800-343-9007 x226.
  • Signature

    As the Authorized Officer, I agree that by submitting this application, I am electronically signing the application and agreeing with the above Terms and Conditions.
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.