2027 Service Center Program

Enrollment request

Fill in your shop details below. The form will prepare an email addressed to Ron Dahlhaus; review it and press Send in your email app to deliver your request.

Prefer paper? Open the 2027 program flyer and printable enrollment form (PDF).

How this works: Your details stay in this browser until you choose to open your email app. This page does not send or store your information automatically.

1 Contact & business information

First name *Last name *Contact role / titleWebsiteEmail address *Business name *Street addressCity

StateZIP codeShop phone *Cell phoneFax

3 Program & account information

Current / primary supplierBuy Wise account numberBuy Wise Territory ManagerTerritory Manager email2027 enrollment planRequested program start date

Your Buy Wise representative can confirm plan details, eligibility, and the start date.

4 Authorization

Authorized person’s printed name *Title

I am authorized to request enrollment for this business and confirm that the information entered is accurate. I understand Buy Wise will review this request and confirm enrollment terms.

An email app must be set up on your device. Your request reaches Ron only after you press Send there.

Your email draft should now be open.

Review the details and press Send in your email app. If nothing opened, copy the request below and email it to Ron.Dahlhaus@samuelsinc.com.

Enrollment request

1 Contact & business information

2 Shop profile

3 Program & account information

4 Authorization