Form Test | Spacelabs Healthcare

Billing Information

Billing Account - Legal Name*

Address Line 1*

Address Line 2

City*

State/Province/Region*

ZIP/Postal Code*

Country*

Would you like invoices emailed instead of sent through regular mail?YesNo

Email to receive invoices

Main phone*

Fax

AP Contact Name

AP Phone

AP email

AP Fax

Business TypeCorporationPartnershipSole Proprietor

Fed ID #

State of Incorporation

Year Business Started

Number of Employees

DUNS Number

Do you export Spacelabs product outside of US?YesNo

TaxableYesNo

Upload tax exemption certificate (max file size 6 MB).

Additional paperwork (max size for total of attached files 20 MB).

Facility Information

Facility Name (if different from above)

Facility Address 1

Facility Address 2

City

State/Province/Region

ZIP/post code

Country

Purchasing Contact Name

Purchasing Contact Phone

Purchasing Contact Fax

Group Purchasing Organization (GPO) member?

GPO Name

Hospital Information

Is facility a hospital?YesNo

Please provide HIN #

Please provide GLN #

Does facility use inhaled anesthesia?YesNo

Number of beds

Shipping Information

Ship-To Name (if different from above)

Delivery Address Line 1

Delivery Address Line 2

City

State/Province/Region

Country

ZIP/post code

Ship-To Contact Name

Ship-To Contact Phone Number

Ship-To Contact Fax

Your Name*

Enter your full name

Your Title*

Your Email*

Enter a valid email

Comments or questions?

Products and services shall be provided to applicant subject to the terms of any contract between Spacelabs Healthcare and Customer applicable to the products and services. If there is no such contract in place, the products and services shall be provided to applicant subject to Spacelabs Healthcare’s standard Terms of Sale available upon request and on our Terms and Policies page. The Terms of Sale are incorporated herein by this reference.

Request Type*

Billing Information

Facility Information

Hospital Information

Shipping Information

Facility Type