CEN-MED ENTERPRISES

Login Information
Please enter your Login information to create your account
* Salutation:		* Email Address:
* First Name:		* Password:(min:6 chrs)
* Last Name:		Confirm Password:

Shipping Information

Please enter the address where your package(s) will be shipped.

* Shipping to

(Company Name):

Attention:

* Address:

(optional)

* City:

* State:

* Zip Code:

(5-digit Zip Code required; Zip + 4 optional)

* Telephone Number:

[ ] - Ext-

Fax:

[ ] -

* Select type of usage:

	Industrial		Research		Hospital
	Laboratory		Physician		Other

Credit Line Information
*What is the complete name of your business:
*Year(s) in business :
What are your annual sales?:
* What is your Federal Tax ID Number:
(Example: 223169845, no spaces or dashes allowed
Other Business Name Used:
What is your DNB (Duns) Number:
Collecting information about your company may take between 1 to 8 business days, which may cause a delay in your order shipment. Please call customer service if you would like your credit check to be expedited.

Billing Information
Please enter your billing information as it would appear on your credit card statement. Accurate information will prevent delays in your order
My billing and shipping information are the same.
* Address:
(optional)
* City:
* State:
* Zip Code:
	(5-digit Zip Code required; Zip + 4 optional)
* Telephone Number:	] - Ext-

Shipping Method
FedEx	Contact me for expedited shipping

Security Information

* Security Question:

* Security Answer:

* Security Code: