New Client Consultation Form

Application for a New Account

Thank you for the opportunity to earn your business
Account Name *
Red Asterisk Denotes Required Field throughout this form
TAX ID NUMBER *
Bill to Address *

Street Address

Street Address Line 2

City State

Zip Code Country
County *
please list your bill to county
Phone Number *

Area Code Phone Number
Ship to Address

Street Address

Street Address Line 2

City State

Zip Code
County *
please list your ship to county
Phone Number *

Area Code Phone Number
Accounts Payable Contact *

First Name Last Name
Accounts Payable Email *
example@example.com
Accounts Payable Phone *

Area Code Phone Number
Purchasing Contact

First Name Last Name
Purchasing Phone Number

Area Code Phone Number
Purchasing E-mail
example@example.com
DEA NUMBER WITH EXPIRATION DATE *
DEA NUMBER AND EXPIRATION DATE
Is Your Business Tax Exempt *

Yes No
Sales Person Name (at AMS) *
Credit Refrence 1
Credit Refrence 2
How Would You Prefer to Pay your bills? *

ACH Draft at time of Shipment ACH Draft on the 29th of the Month Check made payable to Atlantic Medical Solutions with terms of NET30 (subject to approval by Management) Credit Card Autopay at time of Shipment
Your Full Name *

First Name Last Name
Signature *

Sign with your mouse on PC or Finger/Pen on Mobile Clear
Should be Empty:

Application for a New Account