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Facility Type (must check one):

Category: * Required

Physician Office/Clinic

Hospital

Long-Term Care

Surgery Center

Surgical Hospital

Other

If other selected, please specify:

Product Taxable: *

Yes

No

If Entity is taxable but Product is not Taxable, please provide a State Tax Exempt Form supporting Exempt Product (Please consult with your Internal Tax Department or Advisors).

Tax Exempt/Resale Number:

Upload Tax Exempt Certificate

Entity Taxable: *

Yes

No

If no, provide your State Tax Exempt Number and Exempt Certificate.

Distributor Information

Distributor Name

Sales Rep Name

Fax Number

Phone Number

Email Address

Additional Information

For Internal Use Only - CIT Ortho

Entered by:

Entered on:

Facility Information

Practice/Facility Name

Surgeon Name

Email address

Bill To:

Accounts Payable Contact

Phone Number

Address

*NOTE: IF HOSPITAL IS TAX EXEMPT, A COPY OF THE TAX EXEMPTION CERTIFICATE OR LETTER MUST BE FAXED TO CIT ORTHO. AN IRS 501c3 LETTER MAY NOT BE SUFFICIENT TO SUPPORT EXEMPTION.

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This information/document is confidential and proprietary. It may not be reproduced, used or disclosed to others without written consent of CIT Ortho.
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