PTS & CCL New Account Form - Precision Technology Services & Cardinal Contact Lens Inc.

Company Name*

Customer Type

OD
MD
OOD
Other

Buying Group Name (if applicable)

Buying Group Number (If applicable)

Name of Contact: Owners*

Name of Contact: Accounts Payable*

Name of Contact: Office Manager

Name of Contact: CL Technicians

Name of Contact: Customer Service

Company Billing Address (Head office)*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

PST Number (BC customers only)*

If not a BC customer, put "NA"

Billing Email*

Statements will be sent to this email if opting in for email delivery below

Practice Contact Email*

We will send updates on pricing, products, etc.

Phone*

Fax

Other Shipping Address

If the company listed above has additional office locations, please fill out the section below. These are "Ship To" only addresses and will be billed to the Company and address listed above. If you have more than one location and require separate billing for each office, please fill out a separate NEW ACCOUNT REQUEST FORM for each office.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Email

Payment Method*

Payment Terms Net 30 Days. Statements sent out the first week of the month.

EFT or Cheque payment of statement balance
Automatic Credit Card payment of statement balance
Wire Payment (Medmont)
Buying Group Central Billing (ER, OSI, FYI, etc.)

Statement Delivery Method*

Email (preferred)
Standard Mail