Canada LEA Program

Program Submission

Please complete this form and follow all instructions carefully. This will ensure that the agreement will be programmed with the discount terms effective within 1-2 business days of the form submission. If the form is incomplete the new discount terms will not take effect until the agreement is programmed.

Rep Information (Name & TY)*

Rep Name (First & Last) TY#

Rep Email*

Parent Account (Acct # & Name)*

Verify the parent customer’s Legal Entity name and enter it into the form along with the account number.

Parent Acct # Parent Account Name

Branch Account #'s

Please list all branches to be included on program. Use Acct #'s only NOT account names.

Current Program Type*

Select program type customer is currently using.

You MUST select when program terms should take effect*

Delay Program Terms Until:*

Comments (Optional)

Rep Confirmation

Each of these items MUST be confirmed prior to form submission.

Verify Region*

I verify that this account is in region L1.

I agree that I have discussed the terms of this program with the customer and informed them that they all will be taken off any program or promotion they are currently on and the LEA terms will apply to all purchases moving forward (or applicable date selected above).

Canada LEA Program Sign Up