New Customer Form — IZI Medical

New Customer Form

Customer Information

Facility / Company Name

Customer Type

GPO Affiliation

GPO ID (if applicable)

Billing and Shipping Information

Billing Address

Company Name Address

Shipping Address

Company Name Address

Contact Information

AP Contact Information

Name: Email: Phone Number:

Purchasing Contact Information

Name: Email: Phone Number:

Agent Representative (if applicable): Name and Email

Shipping and Payment Information

Shipping Preference

Will default to ground if not specified

Third Party Freight Account # (if applicable)

Tax Exempt?

Yes

Customs Documentation Required?

Yes

If yes, please list required documents.

Anticipated Average Order Size

Order Submission Preference

Payment Preference

Completed By

Name and Email