Concentra PPE: Customer Create

Customer Create

Bold = Required

Italic = Optional

Employee ID: Please enter your employee ID assigned by Concentra Human Resources

Billing String: Please provide your primary 16 digit billing string.

Account Status: New

All accounts are "New" until reviewed for "Approved" status. You will receive an email notification that your account has been approved.

Bill To: same as shipping

First Name:

Last Name:

Email Address:

Phone Number:

Company:

Address:

Address 2:

City:

State:

Zip/Postal Code:

Country:

First Name:

Last Name:

Email Address:

Phone Number:

Company:

Address:

Address 2:

City:

State:

Other State/Province:

Zip/Postal Code:

Country:

Address is a Residence

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