New Customer

Request a Call Back from Your Local Sales Representative

Facility/Customer Name*
Phone Number
Fax Number
Address*
Street Address City State ZIP Code
DBA Name
Alternate Phone Number
Alternate Fax Number
Billing Address*
Street Address City State ZIP Code
Ship to Address
(if different than Billing Address)

Street Address City State ZIP Code
Does your facility have its own shipping account? If so, would you like us to ship your orders on your carrier’s account?
- Yes
- No
Name of Carrier (i.e., Fed Ex or UPS)
Account Number
Purchasing Contact Name*
Purchasing Contact Email*
Purchasing Contact Phone*
Accounts Payable Contact Name*
Accounts Payable Contact Email*
Accounts Payable Contact Phone*
Email Address for Receipt of Invoicing*
Email Address for Receipt of Statements*
Financial Information
Tax Exempt? If Yes, please upload or email a copy of your State Exemption Certificate, MCT Form, and/or SSUTA Certificate with this form.*
- Yes
- No
Upload Tax Exemption Certificate:*
Max. file size: 50 MB.
Does your facility require Purchase Orders?*
- Yes
- No
DUNS Number
Facility Type
Business Type
(Corp, LLC, Partnership, Sole Proprietor, Individual)
Federal Tax ID Number (FEIN)*
Officer/Principal Information
Name
Title
Email
Phone
Name
Title
Email
Phone
Sales Agreement
The undersigned agrees to the MST Terms and Conditions available at https://microsurgical.com/terms-quality-regulatory/. All products are sold by MST FOB MST’s shipping point. The undersigned, in consideration for the terms of sale herein and for the extension of credit terms by Microsurgical Technology, Inc., agrees to pay all amounts due within the terms defined as Net 30. Returned checks are subject to a service charge of not less than $30 for each occurrence. Past due payments are subject to customer credit hold and may incur interest charges. If a dispute arises undersigned agrees to pay all items not in dispute within terms. Venue for any collection or legal action will be King County, Washington. Undersigned agrees to reimburse all reasonable costs of collection and bankruptcy proceedings including, but not limited to, legal, arbitration, collection agency, research and service fees.

The undersigned certifies that the information contained above is true and correct and further agree that any changes in ownership, corporate location, officers or form that the business operates under shall be immediately made know to Microsurgical Technology, Inc., via certified US Mail or via email at [email protected]. The undersigned agrees they are authorized to commit to the terms of this agreement.
Authorized Signature*
Signor must be authorized to commit to the terms of this agreement.
Your Name*
Title*
Email*
Phone*
Email
This field is for validation purposes and should be left unchanged.

Financial Information

Officer/Principal Information

Sales Agreement