*indicates required field
*Type of Account (select one):
New
Prospective
required
*Submitted by
A value is required.
*Legal Entity Name
DBA
*Ship To Address
Bill To Address (if different than above)
*City, State, Zip
*Phone
Fax
*Email
(General)
Invalid
Email
(estatements)
*Contact Person
Doctor(s)
Owner
(if different from above)
If you have not already received Pech price book(s) which would you like to have included with your welcome packet?
C&E
UNCUT
*Preferred method of shipping
UPS Overnight (monthly charges may apply)
UPS 2nd Day (default)
UPS Ground
Crystal Courier (CO only)
ASAP (NE Only)
Post Office
required
Method of billing
Buying Group
Direct Bill
required
If buying group, your preferred group:
If you are affiliated with other Pech offices/accounts please list their name(s):
Sales Representative (if known)
Additional Information needed :
To request special services, please contact your Sales Representative
*
Please enter the following word -
orange
required
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