Up-Lift Technologies Inc. Become a Dealer

Become a Dealer

The Uplift Technologies wholesale and dealer network includes over 1,300 partners committed to providing the best value and service available. If you are a current dealer, or want information on how to join us, please complete the form below and we will be in touch with you.

Please ask about our special “Welcome” offer for new dealers who join us in providing innovative health care solutions.

Fields marked with an * are required.

New Dealer Form

Company Name (*)	Please enter your Company Name
Full Company Address (*)	Please enter your Full Company Address
Phone Number (*)	Please enter you Phone Number
Email Address (*)	Please enter a valid Email Address
Website (*)	Please enter your Website address
Contact Name (*)	Please enter your Contact Name
Are you a Medicare provider? (*)	YesNo Please answer whether you are a Medicare provider
Number of Locations (*)	Please enter your number of locations
Do you work with a referral sources (OT/PT) (*)	YesNo Please select whether you work with a referral sources (OT/PT)
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Number of years in business (*)	Please enter number of years in business
Primary Business Focus (*)	Please select a Primary Business Focus
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