New Account Account Change Form New Client Request/Client Change Form Account Request DescriptionUse this field for notes on this account. Remember, this request/change goes to accounting, Ryan, Rob, and Sarah so use this field to let us know anything unique about the request.Goetze Representative*This is for the Goetze Dental Representative completing the form.Please selectSherry BakerRyan BarbosaGary BowersLarry DalrympleChristian DyerPete DamicoChris ElliottBranden EnstromCurtis GeistNate GlynnVito GomezJustin HinkleCurt HuweJamie JacksonTrevor KelleyBrian LumbardJennifer MattixMike McKimBart MillerHeather MurrayRyan MyersDaniel RodgersJason StowellChris ThomeDennis ThomeCaleb Van CleaveErik WendelGoetze House AccountNew 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 Number Dental License Number Dental License Expiration Dental License State Type of Business EntityPlease SelectLLCPartnershipCorporationIndividualOtherName* First Last Professional Designation DDS DMD MD Specialty*Please selectGPEndoOrthoOral SurgeonPedoPerioDSOCommunity HealthOther - please list in Notes belowDoctor's email address Practice Name* Shipping & Billing InformationShipping Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Contact InformationPractice Email Deliver invoices via email Deliver invoices via email Website URL Phone Number*Mobile Phone NumberFax NumberAP Contact Purchase Order Required?* Yes No PO Contact Tax 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: 256 MB.Business TermsBranch*Please selectKCDes MoinesOmahaSt LouisSpringfieldWichitaDenverGOLGAIN Level Request*GAIN Level Requires Management ApprovalPlease selectPlatinum (Requires Management Approval)Gold (Requires Management Approval)Silver (Requires Management Approval)BronzeRegularPrice List*Please selectT0T1T2T3T4T5T6T7T8T9T10PVL2PVL2-1PVL2-2PVL2-3Waiver of Shipping Charge requires management approval for Trade Price Lists.Small Order Charge waiver requires Credit Card Manual Payment.Waive $8.95 Shipping Charge Waive $8.95 Shipping Charge Waive $9.95 Small Order Charge Waive $9.95 Small Order Charge Small Order Charge TriggerPlease select$99.00 (Trade Price List)$495.00 (PVL2 Price List)Notes