Dental Equipment and Supplies from Atop Dental

Purchaser Contact Information

First Name *

Last Name *

Designator *

Job Title *

Email *

Phone Number *

Create password *

Password confirmation *

Billing Information

+ Display Billing Information

Practice/Business Name *

Practitioner License # *

Phone Number *

Owner *

Street Address *

Postal Code *

Province *

City *

Shipping Information Same as the Billing Information

+ Add Shipping Information

Street Address *

Postal Code *

City *

Province *

Phone Number *

Payment Information

Payment Method *

Country *

Payment Term *

Credit Application (The entire credit check process may take 5‐7 business days to complete.)

***To get Net 30, you need to fill all the following contents.***

+ Add Bank Reference

Institution Name *

Account Rep Contact *

Type of Account *

Institution Number *

Transit Number *

Account Number *

City *

Province *

Postal Code *

Telephone *

Fax *

Email *

Bank Address *

+ Add Trade Reference #1

Company Name *

Contact Person *

Office Address *

Account Term *

City *

Province *

Postal Code *

Telephone *

Fax *

Email *

+ Add Trade Reference #2

Company Name *

Contact Person *

Office Address *

Account Term *

City *

Province *

Postal Code *

Telephone *

Fax *

Email *

+ Add Trade Reference #3

Company Name *

Contact Person *

Office Address *

Account Term *

City *

Province *

Postal Code *

Telephone *

Fax *

Email *

+ Add Additional Information

Target Limit *

Certificate of Incorporation (if applicable)

Business Credit Report (if applicable)

How did you know us? *

Other *

Become a Member (Optional)
Membership: $99 /yr

+ Membership Conditions, Regulations

In this document we will use the name ATOP to describe Atop Dental Canada Inc and its affiliated companies. Acceptance of membership constitutes an agreement to comply with the following conditions and regulations. These conditions and regulations may be amended by ATOP without prior written notice to or consent of the member, but in such cases, the changes made will apply upon the renewal of your ATOP membership.

MEMBERSHIP

Membership is available to dental office.

Membership is non-transferable and non-refundable.

Membership cards can only be used by one office.

ATOP reserves the right to refuse membership to any applicant and membership may be terminated at ATOP’s discretion without cause, as well as for such things as failure to comply with these conditions and regulations or abuse of your membership privileges.

Membership fee is $99 per 12-month period from the date of enrollment of the primary cardholder. This entitles the primary member to one personalized membership card.

All membership fees are subject to applicable taxes.

It will be automatically renewed unless cancelled by either party.

Which Practice Management Software does your office use? *

Which brand of Imaging Software does your office use? *

Who is your current account manager?

*Please accept Atop Term and Conditions*
Yes, I accept Atop Term and Conditions
I agree to receive Atop Email deals.
I agree to receive Atop quarterly mailing Catalogue.

Price Correction Notice

The below registration form is for dental professionals located in Canada and America.

If you already have an account with Atop, please don't fill out this form.

Card Holder Signature (please sign here):

Become a Member (Optional)

MEMBERSHIP

Please accept Atop Term and Conditions

***The below registration form is for dental professionals located in Canada and America.***

*If you already have an account with Atop, please don't fill out this form. *

Card Holder Signature (please sign here):

Become a Member (Optional)

MEMBERSHIP

*Please accept Atop Term and Conditions*

The below registration form is for dental professionals located in Canada and America.

If you already have an account with Atop, please don't fill out this form.

Please accept Atop Term and Conditions