New Business Application | Spectra Baby USA
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Required
Complete each question below and hit submit when finished.
Contact information
1.
First Name
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Required to answer.
2.
Last Name
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Required to answer.
3.
Email Address
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Required to answer.
4.
Phone Number
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Required to answer.
Business information
5.
Business Name
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Required to answer.
6.
Business Type
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Required to answer.
--Select a type
Distributor
Retailer
IBCLC
WEB
Ecommerce
Warranty Customer
7.
In Business Since
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Required to answer.
--Select a year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
8.
Company Website
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9.
Is The Company Tax Exempt?
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Required to answer. Single choice.
Yes
No
10.
DUNS#
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11.
Are you currently working with a Spectra Sales Rep?
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Required to answer. Single choice.
Yes
No
12.
If yes, who?
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Billing information
13.
Billing Name (if different from above)
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14.
Billing Phone Number (if different from above)
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15.
Billing Email
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Required to answer.
16.
Will you be applying for credit terms with us?
. Single choice.
Yes
No
17.
Billing Address
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Required to answer.
18.
Billing Address Line 2
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19.
City
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Required to answer.
20.
State
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Required to answer.
--Select State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Federated States Of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
21.
Zip Code
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Required to answer.
Shipping information
22.
Shipping Address
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Required to answer.
23.
Shipping Address Line 2
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24.
Shipping City
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Required to answer.
25.
Shipping State
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Required to answer.
--Select State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Federated States Of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
26.
Shipping Zip Code
*
Required to answer.
Selling and Scope information
27.
Are you apart of the VGM or Essentially Women GPO/Buying Group?
*
Required to answer. Single choice.
Yes
No
28.
If yes to question 27, what is your VGM# or EW#?
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29.
Do you bill insurance?
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Required to answer. Multiple choice.
Yes
No
30.
Type of Contract
. Multiple choice.
Local
Regional
National
31.
For which providers?
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32.
Who do you sell products to?
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Required to answer. Multiple choice.
End consumer
Wholesale to other retailers
Not for selling/in-house use
33.
How many pumps do you currently sell monthly?
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Required to answer.
34.
What brands of pumps do you currently carry?
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Required to answer.
35.
Which items do you plan on purchasing?
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Required to answer. Multiple choice.
Pumps
Accessories
Pumps & Accessories
36.
What will your order frequency be?
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Required to answer. Single choice.
Weekly
Bi-Weekly
Monthly
Shipping carrier information
37.
We select the most economical shipping carrier for your orders. Would you prefer to use your own carrier account number?
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Required to answer. Single choice.
Yes
No
38.
If yes, which carrier?
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39.
Carrier Account Number
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40.
Do you accept pallet delivery?
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Required to answer. Multiple choice.
Yes
No
41.
Do you have a receiving dock?
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Required to answer. Multiple choice.
Yes
No
42.
Do you require inside delivery?
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Required to answer. Single choice.
Yes
No
43.
Do you have equipment to unload pallets? (forklift, pallet jack, etc..)
*
Required to answer. Single choice.
Yes
No
W9 (pdf doc)
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Tax Exempt
44.
Do you have questions, comments or concerns?
. Multi Line Text.
45.
By checking the option below, the applicant certifies that they're 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.
*
Required to answer. Single choice.
Check
