VGM Canada Application

Welcome to VGM Group Services, Ltd.

Introduction

An Introduction to VGM
Group Services, Ltd.

Services

News and Industry Update

Vanguard Online

Department Directory

Who's who at VGM
Group Services, Ltd.

Sleep Marketing Resource

Members Only Area

Participating Suppliers

Discussion Boards

Forms Library

New! Download a Privacy Policy for your business here

E-Z Web

B.L.U.E.Sheets

Funding Information
by Province

Suggestion Box

Related Links

Get a User Name

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VGM Divisions

VGM Group Services Application

Contact Information:

Group Applying For:

DME/Respiratory

EquipLink (only)

VGMC Fee Structure - $300/month

Company Name:

Phone

Toll Free

FAX Number:

Is your fax machine on at night? Yes No

Mailing Information

Street Address

City

Province

Postal code

Shipping Information

Shipping Address

City

Province

Postal code

General Information:

Do you have an Internet E-Mail address? Yes No

E-mail

Does your company access the Internet? Yes No

Preferred Language

English French

Owners Name

Purchasing Agent

Service Manager

Company Information:

Products / Services provided:

	Manual Wheelchairs		Oxygen Concentrators
	Electric Wheelchairs		Volume Ventilators
	Hi-Tech Rehab Wheelchairs		CPAP/BIPAP
	Beds		Bathroom Safety
	Patient Lifts		Aids to Daily Living
	Wound Care		BIPAP
	Low Air Loss Therapy		Apnea Monitors
	Scooters		Lymphedema Pumps
	Cushions		TENS
	Ostomy		Compression Stockings
	Colostomy		Mastectomy
	Braces		Walking Aids
	Liquid Oxygen		Lift Chairs
	Gaseous / Tank Oxygen		Nutritionals
	Sets of catalogues required (1st set no charge, add'l sets $50.00 each):

Do you currently contract w/ Insurance companies? Yes No

Financial Information:

Contact person for Accounts Payable:
Years in Business:
Business Hours
24 hours on call?	Yes No
Number of employees
Estimated annual Sales:
GST/HST #

Do you carry liability insurance? Yes No
Amount of Coverage:
Do you use any type of equipment financing?	Bank Leasing Co. Manufacturer

Who is your long distance phone service provider?
Do you use cellular telephones?	Yes No
Who is your cellular company?
Do you use PCS communications?	Yes No
Who is your PCS service provider?
Do you use pagers?	Yes No
Who is your pager service provider?
Telephone Contact Person at your company?

Do you have a Web Site?	Yes No
Site Address:
Do you employ a Physio or Occupational Therapist? Yes No
Do you have a brochure on your company? Yes No

Branch Information:

Branch Locations:

Will these locations be ordering product?

Yes ($100 add'l / location) No

Branch #1
Manager
Address
City
Province
Postal Code

Branch #2
Manager
Address
City
Province
Postal Code

Branch #3
Manager
Address
City
Province
Postal Code

Branch #4
Manager
Address
City
Province
Postal Code

By submitting this application, I authorize VGM Home Medical (Canada), Ltd. to obtain or exchange any personal information agent towards establishing or verifying my financial standing including account balances. In addition, I agree to pay VGM Group Services monthly dues in accordance with the fee schedule in effect at the date listed below. I understand that VGM Group Services is under no obligation to grant membership and does not offer exclusive territories. Membership may be cancelled at any time by either party at which time, I further agree that I will cease using any and all trademarks, trade names and any and all other signage or documentation, including but not limited to computer software, Websites, letterhead, business cards and advertising, which signifies my membership in VGM Home Medical (Canada), Ltd., or which may be used by or is associated with VGM Home Medical (Canada), Ltd., upon such cancellation of membership. Participating Suppliers are under no obligation to grant dealership status to VGM Group Services Members.

Authorized Person:

We now accept Visa, Master Card, and Pre-approved Debit Card for monthly dues payment.