01. Primary Service Contact

Hospital / Facility Name

Contact Person Full Name

Position / Department

Direct Phone Number

Professional Email Address

02. Facility Identity & Documentation

Service / Shipping Street Address

City

State

Zip Code

Facility EIN / Tax ID

Tax Exemption Status

Yes No

Please email your Tax Exemption Form and W9 to:

christina.sawyer@clinicalirc.com

*Required to finalize account initialization.

AP Contact Name

AP Contact Email

AP Contact Phone

Preferred Carrier

Carrier Account Number

Shipping costs will be added to invoice if no account is provided.