MWI Financial Solutions Contract Request Form
Requests must be submitted no less than 30 days prior to requested start date.
MWIFS Rebate Value
*
$3,000 to $24,999
$50,000 to $74,999
$25,000 to $49,999
$75,000 or more
OI (with MWIFS cost applied)
*
6% or higher
less than 6%
Territory Number
*
Territory Manager Name
*
Territory Manager Email
*
Region
*
Please Select
R_CA
R_CAR
R_CS
R_EQUINE
R_FL
R_GL
R_GP
R_LC
R_LE
R_LN
R_LS
R_LW
R_MA
R_MW
R_NA
R_NE
R_NW
R_SE
R_TX
Sales Director Name
*
Sales Director Email
*
How many account numbers are associated with this submission?
*
Only 1
2 or more
How many locations are associated with this submission?
*
Please Select
1
2
3
4
5
6
7
8
9
10
11-15
16-20
21+
Primary Account Details
Account Number
*
Account Name
*
Account Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email Address
*
Practice website
*
Number of FTEs
*
Please Select
1
2
3
4
5
6
7
8
9
10
11-15
16-20
21+
Secretary of State Name Search Results
*
Browse Files
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Choose a file
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of
Common Name of Practice
*
Legal Name
*
Should include suffix such as LLC, PLLC, INC, etc.
Guarantor Name
*
Additional Associated Accounts (scroll right for additional questions)
*
MWI Financial Solutions Plan Details
How would you like Reimbursement?
*
Check
Account Credit
Current Annual Sales Volume
*
Qualifying Annual Volume Goal ($) for MWIFS
*
Annual volume, not total volume for total commitment
Term (Years)
*
Please Select
1
2
3
4 (Equipment Plan A only)
5 (Equipment Plan A only)
Rebate Type
*
Front End
Back End
Split
Front End Percent
*
Back End Percent
*
Requested MWI Financial Solutions Plan Contribution Amt. $
*
Months to Payback
*
Can be found on financial solutions calculator
Competitive Match
*
Yes
No
Competitive Program
*
dvmGRO
PSI
MClub
VetSuite
Current MWI Share of Wallet
*
Please Select
0-25%
26-50%
51-75%
76-99%
MWI Strategic solutions?
*
Rows
Existing
Demo Pending
Not Interested
AllyDVM
Synergy
EHS
Hound
RTV
Furscription
AI Scripting
Current Method of Payment
*
ACH/Check
Credit Card
Program Start Date
This MWI Financial Solutions contract will begin on the first of the month following the date you submit this form.
Contract Initiation Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Contract Start Date
*
Account Profile
Established Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Practice
*
Rows
Percent of business (must equal 100%)
Companion Animal
Equine
Bovine
Swine
Is this a new build or existing account?
*
New
Existing
Payment Terms
*
Please Select
N 10th
N30
Auto-ACH
Auto-CC
Other
Please define 'Other'
*
Current GPO
*
Please Select
AAHA Advantage
TVC
Vertical Vet
Vetcelerator
VGP
VMG
None
Current MWI Program
*
Please Select
2C
Independent's Day
NPP
None
NPP End Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Financial Considerations
Future MWI Share of Wallet
*
Please Select
70%
80%
90%
Product Profile
*
Rows
BIAH
Elanco
Merck
Zoetis
N/A
FTHW Brands
Vaccine Brands
Derm Brands
House Brand Utilization
*
Rows
Current User
Open to Use
Not Interested
VetOne
Securos
Growth Opportunities
*
MWI $ Investment in Place
*
Equipment
Weekly Order Frequency
*
Please Select
1-2
3-4
5-6
7+
Tote/Consolidation Commitment
*
Please Select
Consolidation
Totes
Strategic Opportunities
PIMS
*
Compatible
Non-Compatible
Comments
Competitive Risk
Potential risks and options for mitigation
Competitive Offer
Other / Comments
Submit
First Level Approver Details
Are you the approving sales director?
No
Yes
Approver's Name
*
MWIFS Calculator Upload
*
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of
P&L Upload
*
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Other File Upload
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Second Level Approver
Third Level Approver
Fourth Level Approver
Fifth Level Approver
Sixth Level Approver
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