Setup a New Account

Company Name*

Legal Business Name (If different than company name)

Name of Owner/Officer*

Title*

Date started under this ownership*

Phone Number*

Email*

Billing Address*

City*

Zip*

Same As Billing Address

Shipping Address

City

Zip

Website URL*

DUNS#*

Pharmacy License#

Please attach a current PDF copy of your pharmacy license. If one is not provided, your form processing may be delayed.

Tax Status*

Taxable
Non-Taxable

If you selected 'Non-taxable,' please provide a copy of your tax-exempt certificate. If one is not provided, your account will be be defaulted to 'Taxable.'

Are you a Government Agency*

No
Yes-Federal
Yes-State/Local

Buying Group Member*

Yes
No

If yes, please list groups & member ID #’s

Are you related to an existing account with IMS?*

Yes
No

Please provide ALL IMS account numbers that you will need to access. Use a comma (,) after each account number to separate.

Please contact your Territory Manager or Customer Service if you do not know your account number(s) 800.755.3800.

Have you been in contact with an IMS Representative?*

Yes
No

Accounts Payable

Contact Name*

Phone Number*

Email Address*

Purchasing

Contact Name*

Phone Number*

Email Address*

Invoices

Contact Name*

Phone Number*

Email Address*

Trade Reference #1

Company Name*

Account Number*

Contact Name*

Phone Number*

Email Address*

Fax Number

Trade Reference #2

Company Name*

Account Number*

Contact Name*

Phone Number*

Email Address*

Fax Number

Trade Reference #3

Company Name*

Account Number*

Contact Name*

Phone number*

Email Address*

Fax Number

Additional Comments

I authorize Integrated Medical Systems, Inc. (IMS) to contact the trade references provided.

By completing and submitting this form to Integrated Medical Systems, Inc. (IMS), the applicant represents that all of the information contained in this form are true and correct and the applicant agrees that if any of the information becomes outdated or if the applicant learns of a possible or pending change in ownership or management of it or any affiliated facility, the applicant will immediately notify IMS.

Company Representative Full Name*

Company Representative Title*

Company Representative Phone Number*

Company Representative Email*