Company Name
*
Primary Ordering Contact
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Department
*
Designated Account Manager
*
Nick Manitzas
Dayami Cusidor
Ally Landa
Michael Vaturi
613 Med
If no representative has been assigned please select 613 MED as your option
Rep Email
example@example.com
Select Your Preferred Ordering Method(s)
Accounts Payable Contact
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Billing Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Preferred Payment Method
*
ACH
Credit Card
Wire Transfer
Please Attach Your Completed W9 Form
Browse Files
If needed a copy of the W9 form can be downloaded directly at the following link: https://www.irs.gov/pub/irs-pdf/fw9.pdf
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of
Tax Exemption Status
*
Exempt
Taxable
Government
Please Upload your Current Tax Exemption Certificate
Browse Files
Cancel
of
Shipping Address 1
*
Are There any Additional Delivery Locations?
*
Yes
No
Attach your invoice history/item usage including at least the last 90 days of usage.
Browse Files
Cancel
of
Submit
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