Application for Membership Manufacturer Approval Agreement

To Whom It May Concern:

I have recently become a member of CQ Partners and hereby authorize Oticon, Phonak, Resound, Signia, Unitron, Widex and any other similar vendor of CQ Partners (hereinafter a “Strategic Supplier”) to establish a CQ Partners associated account(s) and process all my future orders exclusively on such account(s).

I direct you to immediately terminate and de-activate any accounts I may have previously established with any buying groups (Epic, Fuel, Audigy, Alpaca, AuD-Net, Marcon, Sonus Network, Sonus Elite, Gillum Group, etc.). This termination and de-activation of accounts is applicable to all locations associated with my business, unless otherwise noted below.

I hereby grant CQ Partners authority to manage these accounts on my behalf, including, but not limited to: negotiation of pricing, placing of orders and facilitating payments for products ordered. Please provide to them at their request whatever information they may require to administer our relationship. This authorization will continue for the duration of my membership with CQ Partners.

I further direct that CQ Partners be given thirty (30) days prior written notice for any termination of, or significant changes to, my accounts.

Please contact me directly for verification or if you require any additional information.

With regards,

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NOTE: Additional action will be required. After you click “Submit”, you will receive an email with a link to confirm this application. This application will not be processed until you click the confirm button.