PST/GST Exemption Number
Name of Contact
Accounts Payable Contact:
Name on Card:
HospitalPhysiotherapistRehab CentreOrthotic/Prosthetic ServiceShoe/Foot OrthoticsDistributorSports MedicineRetailerOther
How would you like to receive invoices?
What type of packaging would you like to receive your products in?
Retail - clamshell packagesNon-retail - bags
Please provide at least 3:
Please note: $50.00 minimum order required. Credit terms are net due in 30 days. Orders may be held for overdue accounts. Any orders placed by new accounts will not be shipped until we receive your completed credit application forms. We cannot process your application unless you fill out all necessary fields - to avoid delays, please ensure either your banking or your credit card information is complete before submitting.