Terms Request Form
Account Number
*
Account Name
*
Submitter's Name
*
Submitter's Email Address
*
People to Cc on response from accounting
Internal employees only
Terms Requested
*
Please Select
Split
Delayed Billing
New Practice Program
Amount of Order
*
Minimum vale of $5,000 required
If payment method is CC attach e-mail approval from Regional Sales Director
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Split Months
*
Please Select
2
3
4
5
6
DB Months
*
Please Select
1
2
3
Product Manufacturer(s) and Product(s) Receiving Terms Published Promo Name Exception to Promo Terms? On Pre-Approved List?
*
NPP Start Date
*
NPP TM Questionnaire
*
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NPP Agreement
*
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Submit
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