RIETER MEDICAL SERVICES - APPLICATION FOR NEW CUSTOMER NUMBER
New Customer         Change (Existing Customer - New Ship To)  
BILL TO

CUSTOMER NAME

CONTACT PERSON

ADDRESS

ADDRESS

CITY

STATE

ZIP CODE

PHONE

FAX

 

SHIP TO

SHIP TO NAME

SHIP TO NUMBER

ADDRESS

ADDRESS

CITY

STATE

ZIP CODE

COUNTY

PHONE

FAX

CONTACT NAME

TAX (EXEMPT):

 SEND COPY OF TAX EXEMPTION CERTIFICATE

TAX (NON-EXEMPT):

 PLEASE PROVIDE STATE/COUNTY/CITY TAX RATES

TAX CONTACT:

 mariluz.crespo@rieter.com or fax to 864-542-1917 or phone 864-948-5225