First Name *
Last Name *
Phone Number *
Business Name *
Business Type * WholesaleDMEPharmacyClinicalIBCLCCorporate LactationOther
In Business Since *
Is the company Tax Exempt? * YesNo
Are you currently working with a Spectra Sales Rep? * YesNo
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
Shipping Address *
Are you apart of the VGM or Essentially Women GPO/Buying Group? yesno
If yes to the above, what is your VGM # or EW #?
Do you bill insurance? * YesNo
Type of contract LocalRegionalNational
For which providers?
Who do you sell products to? * End ConsumerWholesale to other retailersNot 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? * PumpsAccessoriesPumps and Accessories
What will your order frequency be? * WeeklyBi-WeeklyMonthly
We select the most economical shipping carrier for your orders. Would you prefer to use your own carrier account #? * YesNo
If yes, Which carrier?
Do you accept pallet delivery? * YesNo
Do you have a receiving dock? * YesNo
Do you require inside delivery? * YesNo
Do you have equipment to unload pallets? (forklift, pallet jack, etc.) * YesNo
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.
3 + 1 = ? Please prove that you are human by solving the equation *
Upon completion of this form, you should receive a confirmation email containing your responses.
If you have not received an email confirmation, please complete the PDF version here and send directly to your Sales Representative or email@example.com