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

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    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.