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General Information
*
Amount Requested
$
*
Existing customer?
Yes
No
Existing nexAir Account Number (if applicable)
NexAir Sales Rep Name (if applicable)
*
Short Description of product(s) to be purchased
Company Information
*
Business Name
Doing Business As (DBA Name)
*
Billing Address
*
City
*
State/ Province
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
*
Zip/Postal
Country
United States Of America
Canada
*
Shipping Address
*
City
*
State/ Province
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
*
Zip/Postal
Country
United States Of America
Canada
*
Accounts Payable Contact Name
*
Telephone
*
Email Address
*
Business Name for Delivery
*
Delivery Contact Name
*
Delivery Contact Phone
*
Delivery Contact Email Address
*
Purchase Order Required
No
Yes
*
Preferred Invoice delivery method
Email
Mail
Fax
Invoice delivery email address
*
Will you act as guarantor for purposes of securing credit
No
Yes
Social Security # for guarantor
If yes attach tax exemption certificate below
*
Tax Exempt
No
Yes
If yes attach copy of medical license below
*
Purchasing Medical Gas
No
Yes
*
Applicant Email Address
Attachments
If applicable, please attach copy of Tax Exempt certificate and/or Medical license. Please provide in PDF format.
Attachment Description
Attachment Location
Upload
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)
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