STOCK HOUSE

ACCOUNT SET UP



Please fill this form out completely to expedite your account set up.

OFFICE INFORMATION


Legal Entity Name Phone Number
DBA EIN Tax ID Number
Business Start Date
Address Line 1
Address Line 2
City State Zip Code
Contact Name E-mail Address


LAB


Laboratory Name Lab Account Number
Bill Through Lab Ship to Account Number


ACCOUNT SET UP PREFERENCES


Which, if any, doctors alliance do you belong to. Default Shipping Method
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LAB SALES CONSULTANT


Name District Manager
E-mail Address Territory Number
Phone Number District Number


Nassau/OOGP SALES CONSULTANT


Name

Submit