Tingle X-Ray, LLC - 5481 Skyland Blvd. E.

- Cottondale, AL 35453 - Phone 205-556-3803 - Fax 205-556-3824

Dealer Application Package

Dear Valued Dealer:

Welcome to the TXR family and we thank you in advance for your support and promotion of the TXR
portfolio of products.

To allow us to meet the requirements of various regulatory bodies, establish your master customer
file, and establish a credit line we ask that you complete and return the following documents that are
hereto attached.

 TXR Dealer Application

 Bank Verification Form
 Sales Tax Resale Certificate Verification Form
 FDA & CE Product Traceability Agreement

To prevent any delay in processing your orders please complete all forms promptly and fax them to
205-556-3824 or scan & email them to [email protected].

We look forward to a long and mutually beneficial relationship with your company and stand ready to
support and assist you.

The TXR Team

Tingle X-Ray, LLC - 5481 Skyland Blvd. E. - Cottondale, AL 35453 - Phone 205-556-3803 - Fax 205-556-3824

Sales Tax Resale Certificate Verification

Company Name: ____________________________________

Address: __________________________________________
City, State, Zip: _____________________________________

Please check the box below that applies to your company’s Sales Tax status.
□ Our company is in a State that has a Sales Tax requirement and we are registered
with the proper authority and possess a current Resale Certificate that is being
provided. Please attach a copy of your current Resale Certificate.

□ Our company is in a State that does not have a Sales Tax requirement. Therefore no
State Sales Tax Authority or Resale Certificates exist.

I certify that the above statement associated with the box checked is true and correct; and that all
purchases from TXR shall be for resale.

______________________________ ___________
Signature Date

______________________________
Printed Name
Tingle X-Ray, LLC - 5481 Skyland Blvd. E. - Cottondale, AL 35453 - Phone 205-556-3803 - Fax 205-556-3824

Dealer/Customer Application

Company Name Primary

Contact

Address Email Address (for Primary

Contact)

City State Zip President or Senior

Officer

Shipping Address (if different than mailing) Sales Manager

City State Zip Service

Manager

Telephone Number Accounting Manager or Controller

Fax Number Number of Full-Time

Employees

Annual Sales Volume Year Established Sales Service

Geographic Coverage Area Resale Number Federal ID No.

Sales Mix:

% New Equipment % Used Equipment % Service %

Consumables

Imaging Modalities:

% CR % CCD/DR % Film

Markets Served:

% GP, Ortho, Clinic % Chiro % Vet

Equipment Manufacturers Represented:

1 2

Other Major Manufacturers

Represented:

1 2

Competitors in Area: (Company Name/Competitive

Product)
1 2

Credit References: (List the 3 Largest) – Please provide credit references of companies that do not
manufacturer x-ray equipment, as competitors typically do not respond to our requests for credit
experience.

COMPANY CITY STATE PHONE FAX

COMPANY CITY STATE PHONE FAX

COMPANY CITY STATE PHONE FAX

Bank Reference:

Name of Bank Telephone Fax

Address Name of Account

Representative

City State Zip Account

Number

Comments:

Undersigned authorizes TXR to contact vendors and financial references for the sole purpose of
obtaining information relevant to disposition of this application for credit. I further understand that all
information obtained by TXR will be kept in the strictest confidence. If open account is established, I
further agree to pay all reasonable costs of collection including attorney's fees incurred by TXR in
collection of any amounts owed TXR by applicant.

Printed Name

Signature Date

PLEASE ATTACH CURRENT BALANCE SHEET AND INCOME

STATEMENT
Tingle X-Ray, LLC - 5481 Skyland Blvd. E. - Cottondale, AL 35453 - Phone 205-556-3803 - Fax 205-556-3824

Dealer Bank Reference Information

Bank
Name

Address

City State Zip

Phone: Fax:

Checking Account #

Date Opened:

Low Account Balance: $

Average Account Balance: $

High Account Balance: $

Saving Account #

Date Opened:

Low Account Balance: $

Average Account Balance: $

High Account Balance: $

Credit Experience

Installment Loans Commercial Loans

Date Opened: High Credit:

High Credit: Balance:

Payments: Collateral:

Balance:

Collateral:

Comments:

Undersigned authorizes the bank named above to release the above limited information to TXR. I further
understand that all information obtained by TXR will be kept in the strictest
confidence.

Printed Name Signature Date

 Tingle X-Ray, LLC - 5481 Skyland Blvd. E. - Cottondale, AL 35453 - 205-556-3803

Customer/Dealer Agreement to Comply with FDA & ISO/CE

Reporting Requirements

FDA Regulation 21 CFR 1002.40 and 1002.41 requires all dealers and distributors to provide the following
information to TXR immediately upon transfer of ownership to their customer.

1. Name and mailing address of the purchaser to whom the product was transferred.
2. Identification and brand name of the product.
3. Model number and serial or other identification number of the product.
4. Date of sale, award, or lease.

21 CFR 1002.41 does allow the dealer or distributor to maintain this information in lieu of providing to TXR.
However, if the dealer or distributor makes this election they must declare this to TXR in writing.

To simplify compliance with these requirements please indicate below which option you choose by checking
the appropriate box.

□ We will forward a copy of Form FDA 2579, Assembler Report of Assembly of a Diagnostic X-ray
System, indicating the location of all certified equipment purchased from TXR within 15 days of
installation.

□ We choose not to provide the information required by 21 CFR 1002.40 to TXR and will, in its place,
comply with 21 CFR 1002.41 and maintain the information for a minimum of 5 years. We will provide
this information to TXR immediately when advised by TXR or the Director, Center for Devices and
Radiological Health, that such information is required for purposes of section 359 of the FDA Act.

Further, we agree that if we cease operations as a business we will provide such information as
obtained pursuant to 1002.40 to TXR prior to ceasing business operations.

Due to the ISO 9001/13485 status and equipment being CE approved of some of our suppliers we are also
required to have all of our customers agree to the below both FDA certified and non-certified equipment and
both medical and non-medical applications:

Report to us all the information about possible incidents involving the device, regarding any
deterioration in its characteristics and performances, as well as any inaccuracies in its
documentation, which might lead to or might have led to the death of patient / user or a
deterioration in his/her state of health. Your signature below attests to your agreement.

Company Name ______________________________________________

_______________________________________ _________________________ _________

Signature Title Date

____________________________
Printed Name