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Company Name*
Date
Billing Address*
City*
State*
Zip*
Shipping address is same as billing address
Shipping Address*
Phone*
Fax
Federal Tax ID
NYS Sales tax Resale: Please include copy Sales Tax Exempt Form
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Purchase Orders Required?*YesNo
Purchasing Manager*
Email*
Accounts Payable Manager*
Account Type* N/AMedicalDental
GPO Affiliation
LIC
All purchases will require credit card payment or cash on delivery. A 3% fee will be assessed for credit card transactions. Customer requesting terms and credit will be required to complete a credit application.