New Customer Form

Purchasing Contact Information

Name of Contact(Required)

First Last

Title and Department(Required)

Telephone Number(Required)

Email Address(Required)

Other Contact Information

(Radiology Manager, Practice Admin, etc.)

Same contact as above?

Yes

Name of Contact(Required)

First Last

Title and Department(Required)

Telephone Number(Required)

Email Address(Required)

Accounting Contact and Payment Information

Name of Accounts Payable Contact(Required)

First Last

Title and Department(Required)

Telephone Number(Required)

Email Address(Required)

Invoice Email Address (if different)

Provide a copy of your completed W9 from(Required)

Max. file size: 128 MB.

A W9 Form can be downloaded here.

Purchase Orders

Will a Purchase Order be issued for transactions?(Required)

Yes

Is a purchase order required before service begins?(Required)

Yes

Payment Terms: Due Upon Receipt

If different terms are requested, please contact [email protected].
For your convenience we accept credit card and ACH payments.

Customer Signature(Required)

Printed Name of Signature(Required)

Tax ID Number and Sales and Use Tax Status Information

Is the company exempt from Sales and Use Tax?(Required)

Yes

Are ALL of your sites exempt?(Required)

Yes

Tax ID Number(Required)

Provide a copy of your tax exemption certificate(s)(Required)

Drop files here or

Max. file size: 128 MB.

Are ALL of your sites exempt? This documentation must be submitted before exemption status is granted. Imperial Imaging Technology policy is to not grant tax exemption status until documentation is provided. As a reminder, your company is responsible for knowing its sales and use tax obligations. Should your company fail to provide this documentation, then your company will automatically be identified within our system as taxable.

Is the company a Reseller?(Required)

Yes

Resale Number(Required)

Please provide a Resale Certificate.(Required)

Drop files here or

Max. file size: 128 MB.

Document Confirmation

Authorized Signature(Required)

Print Name(Required)

Title(Required)

Date(Required)

Company Information

Purchasing Contact Information

Other Contact Information

Accounting Contact and Payment Information

Purchase Orders

Payment Terms: Due Upon Receipt

Tax ID Number and Sales and Use Tax Status Information

Document Confirmation

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