Briumvi

*Denotes mandatory fields

SECTION 1 — LEGAL ENTITY INFORMATION

Legal Entity Name* :

Doing Business As (if applicable) :

Federal Tax ID* :

Organization Type/Class of Trade :

Key Contact Name* :

Key Contact Phone* :

Key Contact E-Mail* :

SECTION 2 — BILLING INFORMATION

Name (if different from Legal Entity) :

Street Address* :

City/Town* :

State* :

Zip Code* :

Billing Contact Name* :

Billing Contact Phone* :

Billing Contact Email* :

SECTION 3 — SHIPPING INFORMATION 1 of 1

Check here if information is the same as Section 2

Name (if different from Legal Entity) :

Street Address* :

City/Town* :

State* :

Zip Code* :

State License :

National Provider Identifier (NPI)* :

DEA Registration Number :

Health Industry Number (HIN)* :

Shipping Contact Name* :

Shipping Contact Phone* :

Shipping Contact Email* :

Click here to add another shipping location/site for this customer.

SECTION 4 — TERMS AND CONDITIONS

Terms and Conditions

* I hereby warrant and represent that (a) the foregoing information is accurate, (b) I have read and agree to the Terms and Conditions, and (c) I have the authority to bind my Account to such Terms and Conditions.

For assistance with your submission, please contact [email protected]

SECTION 3 — SHIPPING INFORMATION 1 of 2

Name (if different from Legal Entity) :

Street Address* :

City/Town* :

State* :

Zip Code* :

State License :

National Provider Identifier (NPI)* :

DEA Registration Number :

Health Industry Number (HIN)* :

Shipping Contact Name* :

Shipping Contact Phone* :

Shipping Contact Email* :