New Customer Form New Customer Form Business Name(Required) Facility Phone(Required)Mobile PhoneBilling Contact Name(Required) First Last Billing Contact Email(Required) Billing Contact Phone (if different from Facility)Billing Street Address(Required) PO Box (if any) Billing City(Required) Billing State(Required) Billing Zip(Required) Shipping Shipping is same as billig Shipping is different Shipping Address if different than billingTax Exempt?(Required) Yes (enter below) no Tax Exemption Number AED Contact is the same as Billing Contact(Required) There is no AED transaction; only training or service Yes, the same No, different (enter below) AED Contact First Last Who will be in charge of your AED maintenance?AED Contact Email AED Contact Mobile PhoneWe use Purchase Orders(Required) No purchase order Yes Purchase order Invoice should be(Required) Email Snail Mail No preference How do you want to receive your invoice?Our terms. Please choose one.(Required) Prepay Credit Card Net 30, credit card (credit app needed) Net 30, check (credit app needed) Net 30, ACH (please forward ACH form to sylvia@vital-education.com) CAPTCHA
