BusinessIQ

General Information

^*Estimated Annual Purchases
$

^*Henry Schein Account No.

^*E-Mail

New Practice?

Select Application Type:

Customer Information

^*Practice / Business Name

Tax ID

^*Billing Street Address

^*City

^*State/ Province

^*Zip/Postal

Country

^*Telephone - Work

^*Email Address

Are you Tax Exempt?
Yes No

^*Application Contact Name

^*Telephone - Work

^*Application Contact Email Address

^*Mailing Address

Mailing Address2

^*City

^*State/ Province

^*Zip/Postal

^*Business Structure

Date Practice Established (or opening):

Practice Specialty:

If Acquired/Merged, By Whom & Date:

P.O. (if required):

^*A/P Contact Name:

^*A/P Contact Phone:

^*A/P Contact E-Mail:

Trade References

Reference Name

Reference Account Number

Phone Number

Reference Name

Reference Account Number

Phone Number

Bank Reference Information

^*Bank Name

^*Bank Account Number

^*Bank Account Type

^*Bank Phone Number

^*Bank Contact Name

Name of Financially Responsible Party

^*Principal First Name

^*Principal Last Name

Principal Social Security Number (SSN)

Billing Address

City

State/ Province

Zip/Postal

Practitioner License #:

^*Practice/Business Name:

DEA Form 223 # (Include Copy)

Attachments

Please attach documents relevant to the application decision process (i.e., company financials, relevant license information, etc)

Attachment Description

Attachment Location

Note: Accepted file formats include PDF, CSV, TXT and various image files (JPEG, JPG, GIF, BMP, TIFF, TIF, PNG, ICO). File attachments must not exceed 10 MB in combined size.

Terms and Conditions

^*Signature of Applicant

^*Title

^*Date

PRINT AGREEMENT

I agree to the terms and conditions specified above.

User Verification

Please complete the following by entering the value EXACTLY how it appears(case sensitive)

Why do I have to do this?


Which state will you be doing business in?


State Name