New Account Set-Up - Checkpoint Surgical

COMPANY NAME*

PARENT NAME (IF APPLICABLE)

PHONE*

FAX*

EMAIL*

ADDRESS*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

ACCOUNTS PAYABLE CONTACT*

BILLING ADDRESS*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

ACCOUNTS PAYABLE PHONE*

ACCOUNTS PAYABLE EMAIL*

TAX EXEMPT?*

YES
NO

If yes, please attach a copy of your tax-exempt certificate.

SHIPPING ADDRESS*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

FEDEX ACCOUNT NUMBER

UPS ACCOUNT NUMBER

Shipping terms will be FOB destination and PPA, unless a FedEx or UPS account number is supplied.

PURCHASING CONTACT*

PURCHASING PHONE*

PURCHASING EMAIL*

PAYMENT TERMS*

All sales by Checkpoint Surgical, Inc., unless covered by a prior existing written contract signed by Checkpoint Surgical, are subject only to the Terms and Conditions found on Checkpoint Surgical’s website. Any terms in customer’s purchase order or any other customer documents which are in addition to, or are different or contrary to these terms, shall have no force or effect.

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Email

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Phone

Email

Fax