Please enable JavaScript in your browser to complete this form. - Step 1 of 3Business Information / Bill To: Business TypeCorporationPartnershipSole ProprietorshipLLCFirm NameD/B/AAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeOwner(s) / Principal(s) *FirstLastPurchasing ContactFirstLastEmail *PhoneWebsite / URLNextShip To: Same as Bill To Address?Contact NameFirstLastAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAcct. Payable ContactFirstLastA/P PhoneA/P FaxA/P EmailTax Information Is this business tax exempt?NoYes (if yes, check on the boxes below)Tax ID #DNB #Product purchased for resale only. Please provide copy of your resale certificateCharitable or nonprofit organization exempt from sales and/or Use Tax. Please provide copy of exemption certificate.Product to be purchased is tax exempt in: Please provide copy of exemption certificate.Update your Resale or Exemption Certificate (if applicable) Click or drag a file to this area to upload. NextCredit Card Information (to be placed on file & encrypted) Name on CardCard TypeVISAMastercardAMEXCredit Card NumberExp. Date (Month/Year)CCV CodeAccount Terms Warranty: We guarantee complete satisfaction on all our products. If you experience issues with one of our products, please contact your AO Sales Rep or call Customer Service. Return Policy: Before returning any product, please call our Customer Service department for an RMA. All returns must be accompanied by an RMA. No returns will be accepted after 30 days from the date of invoice. All returns are subject to a 25% restocking fee. Past Due Balance Policy: I (we) agree that our balance shall be computed at the rate of 1.5% per month (18% APR) on the unpaid balance. I (we) authorize Advanced Orthopaedics, Inc. to charge the unpaid balance, if not paid for by the terms of my (our) account, using the credit card on file. In the Event that is becomes necessary to assign the account for collections, I (we) agree to pay all collection costs and/or if legal action (or appeal) is required, I (we) agree to pay all attorney fees and costs that are incurred. If suite is brought, venue may be laid in the county and state of the creditor’s choice. For past due balances paid using a credit card, I (we) authorize a 5% credit card surcharge. I (we) have read the above terms and conditions and agree to abide by them and Certify that the information given above is complete and accurate. Submitted By *FirstLastToday's DateSubmit
