New Account Request - Metro Optics

New Account Request Form

"*" indicates required fields

Account Name:*

Doctor's Name:*

Primary Contact:*

Position:*

Bill To Address:*

Street Address

City

State / Province / Region

ZIP / Postal Code

Country

Ship To Address:*

Same as Bill To Address

Street Address

City

State / Province / Region

ZIP / Postal Code

Country

Phone Number:*

Fax Number:

Alternative Phone Number (Optional):

Email Address (Shipping Notifications):*

Email Address (Billing Statements):*

MONTHLY BILLING STATEMENTS WILL BE SENT TO THIS EMAIL ADDRESS.

* Metro Optics terms of payment are Net 30. All outstanding invoices are subject to finance charges. We accept Check, Visa or MasterCard as forms of payment. Please sign below verifying you agree to these terms and would like to open an account with Metro Optics under these terms.

I Assume Responsibility For This Account & Any Associated Finance Charges For Late Payment (Type Name Here to Acknowledge Responsibility)

* Metro Optics terms of payment are Net 30. All outstanding invoices are subject to finance charges. We accept Check, Visa or MasterCard as forms of payment. Please sign below verifying you agree to these terms and would like to open an account with Metro Optics under these terms. I Assume Responsibility For This Account & Any Associated Finance Charges For Late Payment (Type Name Here to Acknowledge Responsibility).*

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New Account Request Form

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