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New Customer Form

Company Name *

NYS Sale tax Resale#:(if applicable)

Please include copy Sales Tax Exempt Form (Please attach below)

Federal Tax ID *

Please include copy Sales Tax Exempt Form

Billing Name *

Billing and Shipping are the same

Do you have multiple shipping addresses? *

Yes

Purchase Orders Required *

Yes

Purchase Manager *

Cart Access Names

Accounts Type *

Medical

Dental

Medical License#

Medical license information is required Only when purchasing pharmaceuticals and other RX items.

(Please attach medical license here)

Separate email addresses with a comma.

Submit

All purchase will require credit card payment. A 3% fee will be assessed for credit card transactions.