HPC Customer Form

HPC Customer Form
Customer/Buyer Information

Buyer's Name:Phone:
Buyer's Email:
example@example.com
Facility/Company Name:

Facility Company (Health System) Name:

Facility (Shipping) Address

CityState / Province

Postal / Zip Code
Payment Terms
Accounting/Billing Information:

Email address for Invoices to be sent

Billing Address

City/State/ZipState / Province

Fax Number
A/P Contact Name

First NameLast Name
A/P Contact Email Address:
example@example.com
A/P Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Do you have a corporate shipping account you would like to use?

If Yes, please check which and list your shipper#
Type FedEx 1 UPS ship & bill on my behalf
Shipper# blanks
Is your organization a member of a GPO (group purchasing organization)?
GPO Name GPO Number
How did you find HPC
Primary Areas of Interest (check all that apply)
Departments You Purchase For:

Other
Other topics or books of interest blanks
Other buyers or decision makers at your organization we can connect with on new services or promotions:
Name, Email and Department:
First Name Last Name Email
Name, Email and Department:
First Name Last Name Email
Estimated Annual Book/Resource Purchases:
Is your Organization Tax Exempt?
*We Also require the following be submitted:
- Copy of your Company's W-9
- Sales Tax Exemption form, if applicable
Client herby grants HPC International Inc. the right to use the name and service markes of Client in its marketing materials or other oral, electronic, or written promotions, which shall include naming Client as a client of HP International Inc. and a brief scope of products/services provided.
Referred by
Referral Section
Department Name
Contact Name

First NameLast Name
Contact Email
example@example.com
Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
W-9

Cancelof
Should be Empty:

HPC Customer Form

Do you have a corporate shipping account you would like to use?

Is your organization a member of a GPO (group purchasing organization)?

Other buyers or decision makers at your organization we can connect with on new services or promotions:

Referral Section