New Medical Supply Store Account

Business Name & DBA (If Different) *

Shipping Address *

City *

State *

Zip *

Billing Address

City

State

Zip

Phone *

Fax

Email Address *

Cell Phone Number

Business Hours *

Tax ID #

Should we charge tax? *

How Long Have You Been In Business? *

Do You Own Any Other Medical Supply Stores? If Yes, Provide Name(s) *

Date Business Established

Sales Tax Exemption Number

Anticipated Monthly Purchases (USD):

Type Of Business: *

Sole Ownership

Partnership

Corporation

TRADE VENDOR REFERENCES: U.S. companies with whom you have established business relations:

1. Company *

Telephone *

Address *

Email *

Contact *

Title *

Date Business Relations Established *

2. Company *

Telephone *

Address *

Email *

Contact *

Title *

Date Business Relations Established *

3. Company

Telephone

Address

Contact

Title

Date Business Relations Established

I hereby authorize Alpine Health to contact the above listed references.

Completed By *

Title *

Date *