STOCK HOUSE
ACCOUNT SET UP
Please fill this form out completely to expedite your account set up.
OFFICE INFORMATION
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Legal Entity Name
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Phone Number
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* Required
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* Required
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DBA
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EIN Tax ID Number
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Business Start Date
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* Required
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* Required
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Address Line 1
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* Required
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Address Line 2
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City
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State
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Zip Code
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* Required
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* Required
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* Required
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Contact Name
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E-mail Address
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* Required
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* Required
Invalid Email Format
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LAB
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Laboratory Name
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Lab Account Number
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* Required
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Bill Through Lab
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Ship to Account Number
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* Required
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ACCOUNT SET UP PREFERENCES
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Which, if any, doctors alliance do you belong to.
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Default Shipping Method
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* Default ship method are required |
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LAB SALES CONSULTANT
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Name
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District Manager
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* Required
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* Required
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E-mail Address
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Territory Number
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* Required
Invalid Email Format
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* Required
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Phone Number
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District Number
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* Required
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* Required
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