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VGM Member Application

Fill out the form below and Submit.
Or, if you prefer, print it out,
and fax it to 319-235-9774.
You can also mail it to

VGM & Associates
PO Box 2817
Waterloo, IA 50704

Be sure to call and get information
on our fee structure.

1-800-642-6065
Ask for Jenn, Nancy or Jay
Membership Desired: VGM US Rehab Nationwide Respiratory
How did you hear about VGM? Be specific:  
Please complete all fields:
Legal Company Name
DBA
Business Structure Corporation LLC S Corp LLP
Sole Proprietorship Health System/Hospital
Mailing Address
City, St, Zip
County
Phone Fax
24-hour fax?     Yes No
Toll-Free
   
Owner's Name
Owner's SS#   % Ownership
   
Store Contact Name (If different than owner)
Email Address  
   
Bank Reference:
Contact:
Phone:
   
Medicare #
Medicaid #
Federal Tax ID #
NPI #
   
If different from above please include the following:
Shipping Address
City, St, Zip  
   
Billing Address
City, St, Zip
   
Remit Address
City, St, Zip

Branch Information
Do you have any branch stores?  Yes No
If yes, number of stores 
Branch 1  
  Address
  City, ST Zip
  Phone
  Fax
  Store Manager
   
Branch 2  
  Address
  City, ST Zip
  Phone
  Fax
  Store Manager
   
Branch 3  
  Address
  City, ST Zip
  Phone
  Fax
  Store Manager
   
Branch 4  
  Address
  City, ST Zip
  Phone
  Fax
  Store Manager
   
Number of Employees
Years in Business
Est. Annual Sales
   
List your top 5 vendors and approx. annual volume with each:
1.
2.
3.
4.
5.
   
Accounts payable contact person
   
Do you currently belong to any group purchsing organization (GPO)/buying group?
Yes   No
Who?
   
Do you belong to your State Association? Yes  No
   
Does your company have a website? Yes No
Do you use any type of equipment financing? Yes No
With whom? 
Who is your liability insurance carrier?
Who is your phone service provider?
Accreditation & Certification
Is your company accredited? Yes  No
By whom? JCAHO  CHAPS  NARDS  NRRTS   Other
   
Do you have any employees that are credentialed in the following categories.
HME/Respiratory: CRT
RRT
 
Rehab: NRRTS
CRTS
ATS
PT
OT
   
Participating Vendor Catalog Information
Purchasing Agent  
Phone   Fax  
Catalog Shipping Address
(if different than above)
City, St, Zip 
Please call us at 1-800-624-6065 if additional catalog copies are requested
What products or services are you able to provide?
Product or Service Product or Service Product or Service
Wheelchairs Beds IV therapy
Custom rehab Low air loss therapy Oxygen Concentrators*
Ramps (rental) Patient lifts Liquid Oxygen*
Ramps (built) Patient supports Gaseous Oxygen
Stair lifts Enteral nutrition Transfiling Concentrators
Porch lifts CPMs Portable Oxygen Conc. (POC)
Ceiling lifts Phototherapy Respiratory Meds/Nebs
Elevators Electrotherapy CPAP/BiPAP*
Grab Bars (install) Diabetic Supplies Apnea monitors
Bath Remodels Diabetic Shoes Volume ventilators
Kitchen Remodels Retail pharmacy Sleep Labs
ECUs Lymphedema pumps Unattended Sleep Testing
Wheelchair/Scooter lifts Ostomy/Colostomy Orthotics/Prosthetic
Vehicle modifications Wound care Home Health Services
*required for Nationwide Respiratory membership
Communication is the Key

Here at VGM, we send out timely e-mails on the following topics: General Announcements, Legislative Updates, Vendor Promotions, National Competitive Bidding Updates and Regulatory Updates. Who at your office should receive information on these topics? Please log on to www.vgm.com, www.usrehab.com or www.accesshomeamerica.com and sign up for a user name and password for the "Members Only Area" of the Web site and check off which e-mails you would like to receive.
  • I wish to join The VGM Group company I have chosen above.
  • Dealer must be a VGM Member in order to participate in our specialty networks of US Rehab and/or Nationwide Respiratory.
  • I understand a VGM Associate will contact me with the amount of my monthly dues.
  • I understand that I must stay current (60 days) or will be subject to cancellation.
 
By electronically signing below, the undersigned principal or guarantor of the applicant hereby authorizes VGM to obtain one or more credit profiles on him, her and/or the applicant from a credit reporting agency for use in connection with (a) the transaction currently contemplated, (b) the extension of credit (c) any subsequent updates, renewals, or extensions of the transaction currently contemmplated or credit (d) review or collection of any resulting accounts. In addition, the undersigned hereby authorizes any bank, financial institution or trade reference listed herein to release usual and cosomary business or personal credit information to VGM. A copy of this signed authorization shall be deemed an original for all purposes. I understand that VGM enters contracts with participating vendors to obtain discounted pricing for VGM Members, and that such vendors may pay a fee to VGM not exceeding 3% of the price of goods I purchase from the vendor. A list of participating vendors can be found at www.vgm.com/vendors.asp.
Comments

Owner's Name  
Date 

There may be a few more forms to fill out. After we receive your application a representative will contact you. At that time, you may be asked for more information.

 

 

 
     
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THE VGM GROUP • 1111 W. San Marnan Drive  •  PO BOX 2817 • Waterloo, IA   50704 • 800-642-6065
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