New Customer
Application
Form

Thank you for choosing Imperial Imaging. Please complete the following information to establish your customer account. The information provided will be reviewed by our Accounting Department to determine appropriate payment terms.

1. Company Information

Company Details

Legal Business Name(Required)

DBA (Doing Business As)

If applicable

Company Telephone Number(Required)

Date Business Began(Required)

Business Structure(Required)

If Other, please specify(Required)

Organization Structure

Which best describes your organization?(Required)

Single practice / single location

Part of a multi-location practice or organization

Subsidiary or division of a parent company

Corporate / parent company

Other

Parent or Affiliated Organization Name

If Other, please specify

How Did You Hear About Us?

Referred by an existing customer

Referred by a colleague or business contact

Imperial Imaging representative / sales representative

Online Search (Google, LinkedIn, etc.)

Website

Social media

Trade show / conference

Other

If referred by someone, please provide their name

If Other, please specify

2. Billing & Shipping Information

Billing Address

Billing Address(Required)

Street Address City State Zip Code

Shipping Address

Is your shipping address the same as your billing address?(Required)

Yes

If No, please provide the shipping address below.

Shipping Address(Required)

Street Address City State Zip Code

3. Practice & Service Locations

Will Imperial Imaging be providing services to more than one practice or location under this account?(Required)

No — Single Location

Yes — Multiple Locations

Primary Service Location

Practice / Location Name(Required)

Primary Service Location Address(Required)

Street Address City State ZIP Code

Additional Service Locations

If Imperial Imaging will provide services at additional locations, please list each location below.

Location / Practice Name | Street Address | City | State | ZIP Code

Location 2 — Practice / Location Name

Location 2 —Address

Street Address Address Line 2 City State ZIP Code

Location 3 — Practice / Location Name

Location 3 — Address

Street Address Address Line 2 City State ZIP Code

Location 4 — Practice / Location Name

Location 4 — Address

Street Address Address Line 2 City State ZIP Code

Additional Locations: If you have more locations than can be listed above, please attach a separate location list.

Upload Location List

Max. file size: 128 MB.

Account & Billing Relationship

Are all service locations listed above billed under the same legal company and Tax ID?(Required)

Yes

If No, additional account information may be required for locations that are separately owned or billed.

How would you like to provide separate billing information?(Required)

Enter details in the form

Upload a document

Separate Billing Details(Required)

Please identify which location(s) are billed separately and provide the legal company name and Tax ID for each.

Upload Separate Billing Document(Required)

Upload a document listing separately billed locations with legal company name and Tax ID for each. Maximum file size: 128 MB.

Max. file size: 128 MB.

4. Purchasing Contact

Please provide the primary contact for purchasing and service-related matters.

Purchasing Contact(Required)

First Name Last Name

Title / Department(Required)

Telephone Number(Required)

Email Address(Required)

5. Additional Contact

Please provide another contact, such as a Radiology Manager, Practice Administrator, or other appropriate representative.

Do you have an additional contact?(Required)

Yes

Additional Contact Name

If Yes, please provide the information below.

First Name Last Name

Title / Department

Telephone Number

Email Address

6. Accounting & Payment Information

Accounts Payable Contact(Required)

First Name Last Name

Title / Department(Required)

Telephone Number(Required)

Email Address(Required)

Invoice Email Address

Complete only if invoices should be sent to an email address different from the Accounts Payable Contact.

Upload a completed W-9(Required)

Maximum file size: 128 MB.
A W-9 form can be downloaded here.

Max. file size: 128 MB.

New Customer Payment Review

As part of our new customer onboarding process, our Accounting Department will review the information provided and determine appropriate payment terms. Based on this review, some new customers may be required to prepay their initial order or service. Payment requirements are determined on an individual account basis and may vary based on the customer's account profile, business history, and other factors.

Standard Payment Terms: Due Upon Receipt(Required)

Add initials

If different payment terms are requested or approved, please contact our Accounting Department at [email protected].
For your convenience, Imperial Imaging accepts credit card and ACH payments.

7. Purchase Orders

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

Yes

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

Yes

8. Tax Information

Tax ID Number(Required)

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

Yes

Please upload any applicable tax-exemption documentation.(Required)

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.

Drop files here or

Max. file size: 128 MB.

Is the company a Reseller?(Required)

Yes

Resale Number(Required)

Please upload your Resale Certificate or any applicable documentation.(Required)

Drop files here or

Max. file size: 128 MB.

If Yes: Are ALL of your sites exempt? Provide a copy of your tax exemption certificate(s). 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.

9. Customer Authorization

By signing below, I certify that the information provided in this application is accurate and complete and that I am authorized to establish an account on behalf of the company. I understand that payment terms are subject to review and approval by Imperial Imaging's Accounting Department.

Authorized Customer Signature(Required)

Printed Name(Required)

Title(Required)

Date(Required)

10. Final Review & Submission

Please review all information before submitting your application. Fields marked with an asterisk (*) are required.

New Customer Application Form

1. Company Information

Company Details

Organization Structure

How Did You Hear About Us?

2. Billing & Shipping Information

Billing Address

Shipping Address

3. Practice & Service Locations

Primary Service Location

Additional Service Locations

Account & Billing Relationship

4. Purchasing Contact

5. Additional Contact

6. Accounting & Payment Information

New Customer Payment Review

7. Purchase Orders

8. Tax Information

9. Customer Authorization

10. Final Review & Submission

New Customer
Application
Form