Parametrics Medical
New Customer Registration
Date Created
MM
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YYYY
Company name
*
Please input facility name here.
Company Billing Address (Street)
Company Billing Address (City)
Company Billing Address (State)
Company Billing Address (Zip Code)
Company Shipping Address (Street)
****Please enter if different from above****
Company Shipping Address (City)
****Please enter if different from above****
Company Shipping Address (State)
****Please enter if different from above****
Company Shipping Address (Zip Code)
****Please enter if different from above****
Company Purchasing Contact Name
Company Purchasing Contact Phone Number
###
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-
####
Company Purchasing Contact Fax Number
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Company Purchasing Contact Email
Company AP Contact Name
Company AP Contact Phone Number
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Company AP Contact Email
Do you own a freezer -40c to -80c freezer?
yes
no
Can you accept First Overnight deliveries?
yes
no
Is the facility tax-exempt?
yes
no
Company Allograft Rep who manages the facility?
Company Person Submitted By
*
Company UCN
Company Sales Rep Cell
###
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Company Sales Rep Email
Company Sales Rep WWID
Do Not Fill This Out