ORTHOMERICA - NEW CUSTOMER APPLICATION

Welcome to the Orthomerica Online Customer Application. This online form is the quickest and most efficient way to set up a new customer account with Orthomerica Products. If you need help, would like this form faxed to you, or have questions about our application process, please contact our Credit Department at 1-800-446-6770.

Business Name *

Phone *

Fax *

Billing Address *

Billing Address Line 2

City *

State *

Zip Code *

Country *

Does your company have shipping addresses or locations that are different from the billing address? - If yes, additional addresses will be entered on the next page. * 🛈

Website Address

D/B/A

Federal Tax ID# *

Date Established * +

Estimated Annual Sales $

Type of Business

*

Primary Activities

*

Do you have a trained person on staff that applies braces to patients? *

Officers or Principal Owners:

Name *

Title *

Name

Title

Name

Title

Has the business or any of the Principals ever filed bankruptcy? *

If so, when? +

Primary Contact Person *

Title *

Phone if Different

Primary Email Address *

Would you like us to email all invoices and statements?
No paper copies will be mailed out.

Yes - Email all invoices and statements

Please list each additional email to receive copies.

If you need help, would like this form faxed to you, or have questions about our application process, please contact our Credit Department at 1-800-446-6770.

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