Local: 303-384-3246
Toll Free: 877-386-3246
New Customer
Registration Form
DATE: 2010-09-07
Please complete this entire form. Failure to provide complete information delays processing of this application.
Sales Representative:
 
Company Name & Billing Address
Name:
 
Attention:
 
Address:
 
City, State, Zip:
 
Phone:
 
Fax:
 
Email:
 
 
Shipping Address (if different)
Name:
 
Attention:
 
Address:
 
City, State, Zip:
 
Phone:
 
Fax:
 
Email:
 
 
Business Type:
 Corporation
 Partnership
 Sole Proprietorship
TAX ID:
 
DUNS #:
 
Date Business Established:
 
Accounts Payable Contact:
 
Accounts Payable Phone:
 
Accounts Payable Fax:
 
Accounts Payable Email:
 
 
Officers/Owners
Name:
 
Name:
 
Title:
 
Title:
 
Phone:
 
Phone:
 
 
Is purchase order required?
 Yes       No
 
Is merchandise for resale?
 Yes       No       If yes, please include a copy of resale
 
Is your company tax exempt?
 Yes       No       (or exempt) certificate to 303-384-1904
 
 
Exempt Number:
 
Statement of Financial Responsibility
I hereby certify that I am an authorized signor for the company listed above. I certify that the company assumes financial responsibility, ability and willingness to pay the invoices received from Unisyn Medical Technologies, Inc. in accordance with the terms and conditions therein. In the event of nonpayment, the company agrees to pay all costs incurred for collection, including attorneys' fees.


By checking this box, I agree to the terms above and certify I have the authority to legally enter into this agreement on behalf of the specified organization.
 
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Copyright 2010, Unisyn Medical Technologies, Inc.