New Account
Each customer or B2B person must adhere to the following.
Providing the true Name, address, email ( no gmail, yahoo, aol, outlook allowed for businesses) mailing address phone number ( no google number or forwarded number be allowed.
Medical Supplier New Account Form
Business Information:
- Business Name: __________________________________________
- Doing Business As (DBA): _________________________________
- Business Address: ________________________________________
- City: ___________________ State: ______ ZIP: ____________
- Phone Number: __________________________________________
- Email Address: ___________________________________________
- Website (if applicable): _________________________________
Primary Contact Person:
- Name: _________________________________________________
- Title/Position: ___________________________________________
- Direct Phone: ____________________________________________
- Email: _________________________________________________
Business Details:
- Type of Business: (check one)
☐ Corporation ☐ LLC ☐ Partnership ☐ Sole Proprietor ☐ Other: ___________ - Federal Tax ID (EIN): ____________________________________
- State Resale Certificate Number: ___________________________
- Business License Number: ________________________________
- State Issued: ___________________________________________
Document Uploads (please attach copies):
- ☐ Reseller Certificate
- ☐ Business License
- ☐ W-9 Form (if required)
- ☐ Any other relevant certifications (e.g., DEA license if applicable)
Preferred Payment Method:
☐ Credit Card ☐ ACH Transfer ☐ Net Terms (subject to approval)