New Business Application | Spectra Baby USA
Thank you for your interest in Spectra Baby USA. In order to submit the below application you will need to complete the following questions along with the required documentation:
Required Uploads:
A) W- 9
B) Sales Tax Exemption Certificate, if applicable.
Please tell us more about your company and why you would like to open a Spectra Baby USA wholesale account? (Required)
Complete each question below and hit submit when finished.
Contact information
1.
First Name
*
Required to answer.
2.
Last Name
*
Required to answer.
3.
Email Address
*
Required to answer.
4.
Phone Number
*
Required to answer.
Business information
5.
Business Name as per W9, please upload a copy.
*
Required to answer.
6.
If Division/Subsidary, Name of Parent Company
*
Required to answer.
7.
State of Incorporation
*
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
8.
Business Type
*
Required to answer.
--Select a type
Sole Proprietorship
Partnership
LLC
Corporation
9.
In Business Since
*
Required to answer.
--Select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
10.
Company Website
.
11.
Is The Company Tax Exempt?
*
Required to answer. Single choice.
Yes
No
12.
DUNS# If Applicable
.
13.
Are you currently working with a Spectra Sales Rep?
*
Required to answer. Single choice.
Yes
No
14.
If yes, who?
.
15.
Will you be applying for credit terms with us?
. Single choice.
Yes
No
Business Mailing Address
16.
Name (if different from above)
.
17.
Phone Number (if different from above)
.
18.
Email
*
Required to answer.
19.
Address
*
Required to answer.
20.
Address Line 2
.
20.
City
*
Required to answer.
21.
State
*
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
22.
Zip Code
*
Required to answer.
Accounts Payable Billing information
23.
Billing Name (if different from above)
*
.
24.
Billing Phone Number (if different from above)
*
.
25 .
AP Contact*
.
26.
AP Billing Email
*
Required to answer.
27.
Billing Address
*
Required to answer.
28.
Billing Address Line 2
.
29.
City
*
Required to answer.
30.
State
*
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
31.
Zip Code
*
Required to answer.
Purchase Order Contact:
32.
Name
*
Required to answer.
33.
Title:
*
Required to answer.
34.
Email Address
*
Required to answer.
35.
Phone Number
*
Required to answer.
Shipping information - Primary Location
36.
Shipping Address
*
Required to answer.
37.
Shipping Address Line 2
.
38.
Shipping City
*
Required to answer.
39.
Shipping State
*
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
40.
Shipping Zip Code
*
Required to answer.
41 .
Are there multiple ship to addresses?
Required to answer. Single choice.
Yes
No
Do You Sell Products Through Insurance Reimbursement?
42.
Do you bill insurance?
*
Required to answer. Multiple choice.
Yes
No
43.
Type of Contract
. Multiple choice.
Local
Regional
National
44.
Please list the names of the insurances carriers that you work with.
.
45.
Do you currently sell Spectra Products
*
Required to answer. Single choice.
Yes
No
46.
If yes, who do you currently purchase from.
.
47.
Who do you sell products to?
*
Required to answer. Multiple choice.
End consumer
Wholesale to other retailers
Not for selling/in-house use
48.
How many pumps do you currently sell monthly?
*
Required to answer.
49.
What brands of pumps do you currently carry?
*
Required to answer.
50.
Which items do you plan on purchasing?
*
Required to answer. Multiple choice.
Pumps
Accessories
Pumps & Accessories
51.
What will your order frequency be?
*
Required to answer. Single choice.
Weekly
Bi-Weekly
Monthly
52.
What would be the volume for stated frequency? Pumps only.
.
Shipping carrier information
53.
We select the most economical shipping carrier for your orders. Would you prefer to use your own carrier account number?
*
Required to answer. Single choice.
Yes
No
54.
If yes, which carrier?
.
55.
Carrier Account Number
.
56.
Do you accept pallet delivery?
*
Required to answer. Multiple choice.
Yes
No
57.
Do you have a receiving dock?
*
Required to answer. Multiple choice.
Yes
No
58.
Do you require inside delivery?
*
Required to answer. Single choice.
Yes
No
59.
Do you have equipment to unload pallets? (forklift, pallet jack, etc..)
*
Required to answer. Single choice.
Yes
No
60.
Limited Access Fee
*
Required to answer. Single choice.
Yes
No
61.
Lift Gate Requested
*
Required to answer. Single choice.
Yes
No
62.
Compliance Service Charge
*
Required to answer. Multiple choice.
Yes
No
63.
Appointment Required
*
Required to answer. Single choice.
Yes
No
Additional Information
W9 (pdf doc)
*
Tax Exempt
66.
Brief Company Description
Required to answer.
*
67.
Please tell us more about your company and why you would like to open a Spectra Baby USA wholesale account? (Required)
*
Required to answer.
68.
Do you have questions, comments or concerns?
. Multi Line Text.
69.
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
70.
Authorized Signer for contract / agreement
*
Required to answer.
Required to answer.
71.
Contact to receive legal notices:
*
Required to answer.
Required to answer.
