Home » New Customer Form New Customer Form Company InformationName of Company(Required)Company Telephone(Required)Company Bill To Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Company Ship To Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Date Business Began(Required) Month Day Year Business Structure(Required) Sole Proprietorship Partnership Corporation LLC Other Please List Other(Required)Purchasing Contact InformationName of Contact(Required) First Last Title and Department(Required)Telephone Number(Required)Email Address(Required) Other Contact Information(Radiology Manager, Practice Admin, etc.)Name of Contact(Required) First Last Title and Department(Required)Telephone Number(Required)Email Address(Required) Accounting Contact and Payment InformationName of Accounts Payable Contact(Required) First Last Title and Department(Required)Telephone Number(Required)Email Address(Required) Invoice Email Address (if different) Purchase OrdersWill a Purchase Order be issued for transactions?(Required) Yes No Is a purchase order required before service begins?(Required) Yes No Payment Terms: Due Upon ReceiptIf 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 InformationIs the company exempt from Sales and Use Tax? Yes No Tax ID NumberProvide a copy of your tax exemption certificate(s)(Required) Drop files here or Select files 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? Yes No Resale NumberPlease provide a Resale Certificate.(Required) Drop files here or Select files Max. file size: 128 MB. Authorized Signature(Required)Print Name(Required)Title(Required)Date(Required) Month Day Year Δ
