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, Rob, Katie 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 BowersJared CohenLarry DalrymplePete DamicoChris ElliottNate ElniffCurtis GeistNate GlynnVito GomezJustin HinkleCurt HuweJamie JacksonTrevor KelleyBrian LumbardJennifer MattixMike McKimBart MillerHeather MurrayJason StowellSarah StreamChris ThomeDennis ThomeCaleb Van CleaveErik WendelGoetze House AccountTestNew 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 NumberRep of Record*Please selectSherry BakerRyan BarbosaGary BowersJared CohenLarry DalrymplePete DamicoChris ElliottNate ElniffCurtis GeistNate GlynnVito GomezJustin HinkleCurt HuweJamie JacksonTrevor KelleyBrian LumbardJennifer MattixMike McKimBart MillerHeather MurrayJason StowellSarah StreamChris ThomeDennis ThomeCaleb Van CleaveErik WendelGoetze House AccountDental 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 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 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 Date Format: MM slash DD slash YYYY Please Upload Tax Exempt CertificateBusiness TermsBranch*Please selectKCDes MoinesOmahaSt LouisSpringfieldWichitaDenverGOLGAIN Level Request*GAIN Level Requires Management ApprovalPlease selectPlatinum (Requires Management Approval)Gold (Requires Management Approval)Silver (Requires Management Approval)RegularBronzePrice List*Please selectT0T1T2T3T4T5T6T7T8T9T10BQT1BQT2BQT3BQT4BQT5BQT6BQT7BQT8BQT9BQT10PVL2PVL2-1PVL2-2PVL2-3Waiver of Shipping Charge requires management approval for Trade Price Lists.Small Order Charge waiver requires Credit Card Manual Payment.Waive $7.95 Shipping Charge Waive $7.95 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