1. Company Information

Company Name

Email Address

Phone Number

PST/GST Exemption Number (if applicable)

Bill To Address

Street

City

Province

Postal Code

Country: Canada (Required)

Ship To Address (if applicable)

Street

City

Province

Postal Code

Country: Canada (Required)

2. Contact Details

Sales/Purchasing Contact

Name

Title

Phone

Email

Accounting Contact

Name

Title

Phone

Email

Is this where you would like to receive invoices?

YesNo

If no, where would you like to receive invoices? (email address)

3. Credit Card Authorization

VisaMastercard

Name on Card:

Card Number:

CVV Number:

Expiry Date:

4. Type of Business (check all that apply)

PhysiotherapistRehab CentreOrthotic/Prosthetic ServiceShoe/Foot OrthoticsDistributorSports MedicineRetailerOther

If you would like to set up a corporate account with net 30 days credit terms, please contact us directly at info@orthoactive.com for further assistance. Please contact us if you have any questions about the information being requested.