BusinessIQ

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

^*Zip/Postal

Country

^*Shipping Address

^*City

^*State/ Province

^*Zip/Postal

Country

^*Accounts Payable Contact Name

^*Telephone

^*Email Address

For Access to Manage Account & Ordering

^*Email for nexAir Now Online Account

^*Business Name for Delivery

^*Delivery Contact Name

^*Delivery Contact Phone

^*Delivery Contact Email Address

^*Purchase Order Required

^*Preferred Invoice delivery method

Invoice delivery email address

^*Will you act as guarantor for purposes of securing credit

Social Security # for guarantor

If yes attach tax exemption certificate below

^*Tax Exempt

If yes attach copy of medical license below

^*Purchasing Medical Gas

^*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

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?