Arthrex.Com - Customer Account Forms

Customer Account Forms Customer Request Form

This information/document is confidential and proprietary. It may not be reproduced, used or disclosed to others without written consent of Arthrex, Inc.

Instructions: All fields marked with * sign are required.

Is the Account New?

New Existing

Bill-To Account #

(IF IT'S A CHANGE IN EXISTING ACCOUNT THEN A/C NUMBER IS REQUIRED)

Legal Name of Facility

Facility's Website

DBA, if applicable

How long has this facility been open?

Expected Open Date

Account Type

Do you have access to place online orders?

Yes No

Would you like access to place orders online?

Yes No

(IF YES, PLEASE PROVIDE EMAIL ADDRESS TO BE ASSOCIATED WITH ONLINE)

Primary Account User Email

For any additional changes, please click here to expand this form and fill only the fields that you want to update.

Are you a buying group Member?

(IF YES, THEN PLEASE SELECT FROM DROP DOWN LIST)

GLN (Global Locator Number)

Do you have a primary GPO?

(IF YES, THEN PLEASE SELECT FROM DROP DOWN LIST)

Secondary GPO?

(IF YES, THEN PLEASE SELECT FROM DROP DOWN LIST)

Ship To Account Details

Is this New Ship-To or update to Existing Ship-To address?

New Existing NoChange

Name of Facility

Ship-To Account#

How long has this facility been open?

Expected Open Date

Bill To Address

Ship To Address

Same As Bill To

Address

City

County

State

Zip

Country

Credit and References

Credit amount requested $

($25,001 AND OVER REQUIRES REVIEW BY CREDIT TEAM)

Trade References

Reference 1:

Reference 2:

Company Name

Account #

Phone

Fax

(Preferred)

Contact

Address

City

County

State

Zip

Country

Have you had a prior bankruptcy in last 10 years?

Yes No

(IF YES, PLEASE PROVIDE CASE NUMBER)

Case number

Purchasing Detail

Contact Name

Contact Email

Phone

FAX

Name Of Person Completing Form

Phone

Additional Comment

Type of Change Requested

Please acknowledge the confidentiality agreement before submission.

Confidentiality. The Applicant acknowledges that all pricing provided by Arthrex is “Confidential Information” and shall not be disclosed to any third party except for a party’s employees, attorneys, or accountants (“Third Party”) on a need-to-know basis to perform services utilizing Arthrex Products; provided that such Third Party is under a written obligation of confidentiality. Applicant further acknowledges that pricing will not be sold, shared, or bartered in exchange for compensation or services rendered.

Instructions: All fields marked with * sign are required.

Ship To Account Details

Bill To Address

Ship To Address

Credit and References

Trade References

Reference 1:

Reference 2:

Purchasing Detail

Accounting Detail

Invoice and Statement Delivery Preferences