Dinex Loyalty Program Agreement

Please verify you have the correct addresses and item information before submitting the form.

You can use the Dinex Free Goods Contracts to find order information.

Our Dinex Loyalty eForm is available for download here.

Facility Information

Rep Group *

Facility Name *

National Account Name *

Contact Name *

Address *

City *

State *

Zip Code *

Phone *

Email *

Beds *

Avg. Census *

Check One *

Hospital

Long Term Care

Room, Delivery Per Meal

Distributor Information

Is this renewal or a new program? *

New Order

Renewal

A renewal is an instance which the facility has been part of the Loyalty Program within the last three years

GPO Name

Distributor Name *

Contact Name *

Address *

City *

State *

Zip Code *

What Product Brand Are You Currently Using? *

Rep Group *

QTY/Product/Color
Product #	Qty Free*	Color Code*
Product #	Qty Free *	Color Code *

Agreement

The Term of this Agreement shall be for a minimum of one (1) year beginning with the initial shipment of products indicated in this Agreement. The Facility agrees to purchase from an authorized DINEX®|Carlisle Distributor, all of the goods listed during the term of this Agreement. DINEX® will provide to the Facility an invoice for “free goods” indicating that there will be no charge for the Mug, or Tumbler and Bowls. The invoice will indicate the value of the “free goods” delivered pursuant to this Agreement. The Facility should report the value of the “free goods” as a discount from the per case price in accordance with the invoice in compliance with the “safe harbor” reporting obligations under applicable Health and Human Services regulations. In the event the Facility does not purchase its requirements of lids from DINEX’s authorized distributor during the term of this Agreement, the Facility hereby agrees to pay the value of the “free goods” indicated on the invoice. Failure to comply with the terms of the Free Goods Agreement will be cause for DINEX® to invoice The Facility for the Free Goods provided.

Signature *

By typing my name, I acknowledge that I am authorized by the above named Facility to enter into this Agreement on its behalf. Further, I acknowledge that I have read and understand all of the terms and conditions herein.

Date *

Month

Day

Year

Please enter the Contract Date

Title *

Contract forwarded to DINEX® by

Phone

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Attach Lid Usage Report *