New Customer Form

INTRAUMA New Customer Form (all fields are mandatory)

Date *

Name of Practice or Hospital *

Ship to address *

City *

State *

Zip *

Billing address *

City *

State *

Zip *

Phone *

Email *

VAT#/EIN#/FID# *

Owner / Head Surgeon *

Part of a corporation? *

Corporation name

Part of a Surge group *

BILLING INFORMATION: Send Invoice - Attn: *

Accounts payable email *

Purchasing contact email: *

PO#'s required? *

PREFERRED PAYMENT METHOD:

Privacy Policy

by signing this consent I declare pursuant to and in accordance with article 6 of the EU Regulation 2016/679, *

I authorize to send promotional newsletters, commercial or advertising communications or events organized by Intrauma S.p.A. via email. *

Via Genova, 19
10098 Rivoli (To) – Italy