New Hospital Short Form

Please remember to submit the following form once you are complete.

If you have any questions, do not hesitate to reach out to customer service at 800.635.6779 or customerservice@datadistributing.com

If you would like to download this form instead, please click here.

Company Information


CorporationPartnershipIndividualLimited Liability Company

Accounts Payable Information

Sales Info

Tax Information

Sales tax will be added to invoices for shipments into California, Illinois, and Washington,
unless customer is either a Reseller or Tax Exempt.


YesNo

If yes, provide Resale Certificate for each applicable state.
(Seller's Permit does not meet requirement for deferring sales tax.)


YesNo

If yes provide Tax Exemption Document

Bill To Address

Ship To Address

Same as "Bill To"? If yes, then skip section.