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Hearing Professionals Buying Group

Collective Buying Power...

Maximize Business Results

MEMBERSHIP APPLICATION

To become a member of DART Alliance, Inc., please completely fill out the form below. Once this application
has been processed, you will receive a confirmation and your account will be coded. Please fax a signed copy
of this application to 513.598.8223 or mail it to the address below.

COMPANY INFORMATION
Company Name
Doing Business As (DBA)
Authorizing Name/Title
Mailing Address
City/State/Zip
Phone
Fax
Email
Ownership
‰Corporation ‰Partnership ‰Individual ‰ Non-Profit
Years in Business
Federal Tax ID #

PRINCIPALS
Name and Title Name and Title

Mailing Address Mailing Address

City/State/Zip City/State/Zip

Phone/Fax Phone/Fax

Email Email

6570 Glenway Avenue • Cincinnati, Ohio 45211 • 1-888-801-1107

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Hearing Professionals Buying Group

Collective Buying Power...

Maximize Business Results

TRADE REFERENCES MANUFACTURERS ACCOUNT NUMBERS

Business Name Phonak
Address ReSound
City/State/Zip Siemens
Phone Unitron
Account #

Business Name
Address
City/State/Zip
Phone
Account #

MEMBERSHIP PROFILE (check one)

‰Audiologist ‰Hearing Aid Specialist ‰Medical Specialist ‰ Other (please specify)

License Number
Number of years in the hearing field
List (3) manufacturers you most frequently buy from
CONFIDENTIALITY
The undersigned applicant agrees that all training and promotional materials supplied by DART will be kept
confidential by the applicant, and applicant will return all copies of training materials and unused supplies of
promotional materials when applicant’s membership terminates. Applicant further agrees not to use such materials at
any time to promote or sell products or services which have not been approved by DART for its Associates.

PURCHASE AGREEMENT
The undersigned applicant hereby agrees that the Law of Ohio and the terms and conditions set forth on this
application for membership shall apply to all purchases by the applicant, and the undersigned agrees to be legally
bound thereby.

TERMS OF PAYMENT
Payment for all purchases of merchandise and services from individual manufacturers is due directly to the respective
manufacture. Terms of payments will be provided by each manufacturer.

RETURN PRIVILEGE
Terms of return privilege will be provided by individual manufacturers.

Signature Date

Printed Name