First Name *
Last Name *
E-Mail Address
Phone Number *
Business Name *
Business Type * Wholesale DME Pharmacy Clinical IBCLC Corporate Lactation Other
In Business Since *
Website
Is the company Tax Exempt? * Yes No
DUNS#
Are you currently working with a Spectra Sales Rep? * Yes No
If yes, who?
Billing Name (If different from above)
Billing Phone Number (if different from above)
Billing E-Mail *
Check this box if you will be applying for credit terms with us
Billing Address *
Address Line 2
City *
State *
Zip *
Shipping Address *
Address Line 2
City *
State *
Zip *
Are you apart of the VGM or Essentially Women GPO/Buying Group? yes no
If yes to the above, what is your VGM # or EW #?
Do you bill insurance? * Yes No
Type of contract Local Regional National
For which providers?
Who do you sell products to? * End Consumer Wholesale to other retailers Not for selling/In-house use
How many pumps do you currently sell monthly? *
What brands of pumps do you currently carry? *
Which items do you plan on purchasing? * Pumps Accessories Pumps and Accessories
What will your order frequency be? * Weekly Bi-Weekly Monthly
We select the most economical shipping carrier for your orders. Would you prefer to use your own carrier account #? * Yes No
If yes, Which carrier?
Account number
Do you accept pallet delivery? * Yes No
Do you have a receiving dock? * Yes No
Do you require inside delivery? * Yes No
Do you have equipment to unload pallets? (forklift, pallet jack, etc.) * Yes No
Do you have questions, comments or concerns?
By checking this box, the applicant certifies that it is an authorized employee of the company mentioned in the above application. Furthermore, the applicant authorizes Spectra Baby USA to contact the company regarding the above application.
1 + 3 = ? Please prove that you are human by solving the equation *
