New Customer Worksheet

^* Required fields

CUSTOMER NAME

CHECK ONE: HospitalASC/ClinicDr Office

SHIP-TO INFORMATION

^*Department Name or Attention:

^*Address Line 1

Address Line 2

^*City

^*State

^*Zip

^*State License #

^*State License Exp Date

^*DEA #

^*Order Processing Contact Name

^*Order Processing Contact Phone

^*Order Processing Contact Email

^*Receiving Contact Name

^*Receiving Contact Phone

^*Receiving Contact Email

BILL-TO INFORMATION

^*Department Name or Attention:

^*Address Line 1

Address Line 2

^*City

^*State

^*Zip

^*Accounts Payable Contact Name

^*Accounts Payable Contact Phone

^*Accounts Payable Contact Email

^*Form Completed By Name

^*Phone

^*Email

^*Date

Minimum order quantity is 9 kits (9 kits = 1 case).
No returned goods accepted or credit memos issued, except for product shipped in error by Photocure, Inc. or products damaged in transit. Must be reported to Photocure, Inc. within ten (10) business days of receipt
and must be returned to Photocure, Inc. within 25 days of receipt. Contact Photocure, Inc. customer service at 1-855-297-8439 phone or 1-414-434-6952 fax.
Payment terms are 30 days, unless exception is approved by Photocure Finance Director.
Shipping FOB destination by ground standard delivery with prepaid freight passed through to customer.
All orders received by 2 pm CST will ship from the warehouse the next business day.
Customer agrees to pay expediting fee and overnight shipping fee if those services are requested.
Late payment interest 1% per month as allowed by law.