New Customer Application

You are applying to be set up as a ZOLL customer. Please complete the form below.

Your request will be processed as quickly as possible and you will receive an email with your login credentials when the setup process is complete.

General Company Information

Company Name

Billing Address

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Billing City

Billing State

Billing Zip

Billing Country

Owner/Owners

Shipping Address

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Shipping City

Shipping State

Shipping Zip

Shipping Country

Web Store User Information

First Name

Last Name

Phone

E-mail

General Company Contact Information

First Name

Last Name

Phone

Purchasing contact name

Phone

E-mail

Corrective Action contact name

Phone

E-mail

General Company Business Information

Business website (if applicable)

Type of business

How long in business

Duly authorized representative

Sales tax status

Please note a tax exempt certificate is required for each state to which tax exempt purchase is shipped. If a tax exempt certificate is not provided, tax will be billed and payment of the tax will be the responsibility of the customer.

Company Fax Number

For profit or non-profit

Is this for resale?

Member of purchasing group or contract

If yes, name of group or contract

What IDN System is this facility a part of?

GPO Member ID #

*Required Fields

Customer account management helps us to maintain our commitment to excellence by allowing us to process your orders accurately and efficiently. FDA requires ZOLL Medical to track serial numbers by customer location.

* Payment Terms-Net 30 Days / Shipping Terms–FOB Shipping Point / Freight Terms-Prepay and Add

* Terms of Payment: Unless otherwise stated, payment by the customer is due thirty (30) days from the invoice date appearing on ZOLL Medical Corp invoice. If ZOLL Medical Corporation uses a collection agency or legal action to recover monies due, customer will be liable for all expenses we incur to recover such monies, including attorney’s fees

Agree to Terms