Please print and complete the following application and return it signed either one of these two ways:
   • Mail to: Positive Image Orthotics, Inc., 239 Avenel Street, Avenel, NJ 07001
   • Fax to (732) 286-4445

"POSITIVE IMAGE LICENSED IMAGES ON PAPER TRANSFERS ARE
ONLY AVAILABLE TO AUTHORIZED POSITIVE IMAGE MANUFACTURERS"

Name of Facility:___________________________________________________________

Street Address:____________________________________________________________

City:__________________________ State:______________ Zip:_________________

Phone:_____________________________ Fax:______________________________

Name of Practitioner:______________________________________________________

Are you currently Certified to practice Orthotics by a recognized Certifying Organization?     Yes____ No____

If "Yes", Name of Organization:_____________________________________________

Certification Number:______________________________________________________

What is the number of Certified and / or Registered technicians employed at this facility?_________

I,_______________________________ being duly sworn declare that I have entered all the information within this application truthfully and without reservation. I understand and acknowledge that as an authorized Positive Image ® Bracing System Manufacturer I accept all responsibilities and liabilities for any and all manufacturing defects that might occur on any orthosis that is manufactured by me and / or anyone else employed at the above named facility and not directly manufactured by Positive Image Orthotics, Inc.

I further acknowledge that under no circumstances is Positive Image Orthotics, Inc. or any other corporation that Positive Image ® Orthotics, Inc. is under contract with for the use of licensed properties liable for any damage due to a manufacturing defect that might occur on a Positive Image ®, orthosis that has been manufactured by me or anyone else at the facility named in this application.

I also understand and agree that all Positive Image ® paper transfers are to be used for Orthotic and / or Prosthetic devices only and are not to be resold.

Signature of Applicant:____________________________________

Print Name and Position:____________________________________

Sworn to this _________ Day of __________________, 19_________