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Hillrom Parts Store
Business Account Setup

Thank you for your submission

This form is subject to Hill-Rom's approval. Written notice shall be given to Customer within 30-days of the date the form is submitted by Customer to Hill-Rom in the event Customer's application is rejected due to credit worthiness or such other factors in the sole discretion of the Hill-Rom, to be unsatisfactory.

Please enter all required fields

Business Account Setup

1. Shipping Information

2. Billing Information

3. Other Information

4. Required Documents

5. Review & Confirm

Shipping Information

All fields are required unless otherwise specified

Facility Name or Home Care Individual

Full Name of requestor

Account is for direct.hill-rom.com

Requestor phone number

Requestor email address

Your Facility's Global Location Number(optional)

Address

Address Line 2(optional)

Address Line 3(optional)

City

State/Province

Postal Code

Country

Phone

Fax(optional)

Customer Type

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Billing Account

All fields are required unless otherwise specified

Account Name(i.e. Sold To)

Existing Hillrom Account Number(optional)

Existing Welch Allyn Account Number(optional)

Billing Address

Same as Shipping Address

Address

Address Line 2(optional)

Address Line 3(optional)

City

State/Province

Postal Code

Country

Phone

Fax(optional)

Email

FedEx or UPS Shipping Number(optional)

Carrier

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Accounts Payable Contact

All fields are required unless otherwise specified

Contact Name

Phone

Email

Tax Exempt
if yes, please fax or Email tax exemption certificate to 812-931-3208. Attn: Shawn Taylor or Upload File

(optional)

Government Agency(optional)
if yes, Select Type

Additional Information

Customer Type

Is Owned by Hospital and part of a group?

Name of Sales Rep Requesting Account
(Hillrom/Welch Allen employees, recommended to be completed)

Email of Sales Rep
(Hillrom/Welch Allen employees, recommended to be completed)

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Required Documents

Please Upload any relevant documents (i.e. W-9, Provincial Tax Exemption form):

(optional)

Comments to include with your Registration(optional)

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Review Your Information

Shipping Information

Facility Name or Home Care Indiv idual

Account is for direct.hill-rom.com:

Requestor Name:

Requestor phone number:

Requestor email address:

GLN:

Address:

Address Line 2:

Address Line 3:

City:

State/Province:

Postal Code:

Country:

Phone:

Fax:

Customer Type:

Billing Information

Account Name:

Hillrom Account Number:

Welch Allyn Account Number:

Address:

Address Line 2:

Address Line 3:

City:

State/Province:

Postal Code:

Country:

Phone:

Fax:

Email:

FedEx or UPS Account Number:

Carrier:

Other Information

AP Contact:

AP Contact Phone:

AP Contact Email:

Tax Exempt:

Tax Exempt File:

Government Agency:

Government Agency Type:

Customer Type:

Sales Rep:

Sales Rep Email:

W9 file 1:

W9 file 2:

Comments:

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Business Account Setup<br/>Your browser does not support JavaScript!

Shipping Information

Billing Account

Billing Address

Accounts Payable Contact

Additional Information

Required Documents

Review Your Information

Business Account Setup