New Customer Account Form
Prescott's Inc.
18940 Microscope Way
Monument, CO 80132
Phone: 800-438-3937
Fax: 719-488-2268
 
Information on this form must be filled out completely
Required FieldCompany Name 
Required FieldBilling: Address line 1 
Billing: Address line 2 
Required FieldBilling: City 
Required FieldBilling: State 
Required FieldBilling: Zip/Postal Code 
Use this address as my shipping information 
Required FieldShip To: Name 
Required FieldShip To: Address 1 
Ship To: Address 2 
Required FieldShip To: City 
Required FieldShip To: State 
Required FieldShip To: Zip Code 
Required FieldAP Contact: First Name 
Required FieldAP Contact: Last Name 
Required FieldAP Contact: Telephone # 
AP Contact: Email Address 
AP Contact: Fax# 
Required FieldPurchasing Contact: First Name 
Required FieldPurchasing Contact: Last Name 
Required FieldPurchasing Contact: Telephone # 
Required FieldPurchasing Contact: Email Address 
Purchasing Contact: Fax # 
Required FieldW-9 
Please provide a copy of your W-9
Required FieldFed Tax ID# or SS# 
Please no special characters, only numbers
Are you Tax Exempt? 
*Please send copy of tax exemption or resale certificate to hrslorach@surgicalmicroscopes.com*
Tax Exemption # 
UPS Account Number 
Please provide your UPS shipping account # if you have one.
FedEx Account Number 
Please provide your FedEx shipping account # if you have one.
Terms