Providers/Dealers & General Inquiries: 800-800-8586
Consumer/End User Support: 800-800-4258
Consumer/End User Sales: 800-800-3794
Pride Mobility Products Corp.
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REF: COM/0106-2
Rev: 0 Date: 4/1/14
Approved by: Julie Piriano

Pride Provider Standards Violation Notification

Pride Mobility Products Corporation has developed provider standards for the benefit of our providers and the good reputation of Pride.

Violation of any of the standards will be investigated and may result in the termination of the provider's right to purchase products from Pride Mobility Products Corporation. Please note if you notify us of a violation, you will not receive a response regarding the outcome of our investigation and, if applicable, any action taken against the violator.

Please complete a separate form for each alleged violation.

Individual or Company Name:

Address:

,

Phone Number:

Nature, facts and/or evidence of the violation:

Date(s) of violation:

Format: dd/mm/yyyy Multiple dates seperate by commas(,).

Name of Product:

Model Number:

Additional Information and/or other Pride Provider Standards Policy Violation(s) Noted:

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Pride Mobility Products Corporation - Disclosure Statement Pursuant to Cal. Civ. Code 1714.43(a)