Certified AmeriGlide Reseller

To begin the process of becoming a Certified AmeriGlide Seller, please fill out the form below. Please do not call. After we have received your submission, we will contact you if you qualify for our program.

Company Name
Legal Business Name
Owner's / Partner's / Member's Name
Business Street Address
City
State
Zip
Phone
Fax
Federal Tax I.D. #
D&B#
Purchasing Contact
Email Address
Date Present Business Began
Years At This Address
Type of Business
Type of Ownership
Reference 1
Phone
Street
City
State
Zip
Reference 2
Phone
Street
City
State
Zip
Reference 3
Phone
Street
City
State
Zip
Bank Name
Bank Contact
Phone
Fax
Street Address
City
State
Zip

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Phone:1 (800) 790-1635 Fax:1 (800) 791-6524

National Aging in Place

We take checks as well as major credit cards.