New Account Account Change Form New Client Request/Client Change Form Account Request DescriptionUse this field for notes on this account. Goetze Representative*This is for the Goetze Dental Representative completing the form.Please selectRyan BarbosaGary BowersPete DamicoChris ElliottBranden EnstromCurtis GeistNate GlynnVito GomezTrevor KelleyBart MillerDaniel RodgersJason StowellMichael PottertonCaleb Van CleaveErik WendelGoetze House AccountJared CohenSherry BakerNikki BunchLaura PielErika OlendorffChase WrigleyNew Account or Account Change Request*Is this a new account or a change request for an existing account?Please selectNew AccountExisting AccountCorporate Group Account?Is this account part of a Corporate Group Account? If so, please list doctor name and existing account number.Existing Account NumberDental License NumberDental License ExpirationDental License StateType of Business EntityPlease SelectLLCPartnershipCorporationIndividualOtherName* First Last Professional Designation DDS DMD MD Specialty*Please selectGPEndoOrthoOral SurgeonPedoPerioDSOCommunity HealthOther - please list in Notes belowDoctor's email addressPractice Name*Shipping & Billing InformationShipping Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Please verify USPS addressBilling Address Billing is same as shipping Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Payment TermsPlease SelectNet 10 EOMCC ManualCC MonthlyContact InformationPractice Email Deliver invoices via email Deliver invoices via email Website URL Phone Number*Mobile Phone NumberFax NumberAP ContactPurchase Order Required?* Yes No PO ContactTax Exempt Certificate is Required or Customer is Liable for Paying Sales TaxTax Exempt Tax Exempt Tax Certificate #Expiration Date MM slash DD slash YYYY Please Upload Tax Exempt CertificateMax. file size: 300 MB.Business TermsBranch*Please selectKansas CityDes MoinesOmahaSt LouisSpringfieldWichitaDenverGOLGoetze Dental Loyalty Program*Please selectUnite (Enrollment Form Required)Platinum (Requires management approval. Min $5000/month)Gold (Requires management approval. Min $3000/month)Select (Min $1500/month)RegularPrice List*Please selectT0T1T2T3T4T5T6T7T8T9T10PVL2PVL2-1PVL2-2PVL2-3PVL3Waiver of Shipping Charge requires management approval for Trade Price Lists.Small Order Charge waiver requires Credit Card Manual Payment.Waive $10.95 Handling Charge Waive $10.95 Handling Charge Waive $9.95 Shipping Charge Waive $9.95 Shipping Charge Notes