New Client Contact Form

New Customer Account Setup

Business Information:

Company Name*

Date

Billing Address*

City*

State*

Zip*

Shipping address is same as billing address

Shipping Address*

City*

State*

Zip*

Phone*

Fax

Federal Tax ID

NYS Sales tax Resale:
Please include copy Sales Tax Exempt Form

Upload File :

Purchase Orders Required?*YesNo

Purchasing Manager*

Phone*

Fax

Email*

Accounts Payable Manager*

Phone*

Fax

Email*

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.