Please complete the following form and attach your completed W-9 and serial number. Requested By * Hospital Name * Contact Name * Position * Street * City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Remit to Address if Different from Above * Telephone * Email Address * Product(s) Purchased * DuraTherm Smart•Therm Serial Number(s) of New Dinex Unit Received * Serial Number(s) of Unit Being Replaced * PO Number/Order Number * W-9 Form * Files must be less than 2 MB.Allowed file types: gif jpg jpeg png eps tif pdf. What method of reimbursement do you prefer? * ACH payment Issue the Distributor a Credit Memo Routing # * Account # * Remittance email address * *Please note the credit memo will be issued to the distributor you placed your order through. You will need to follow up with your distributor contact to ensure the credit was posted. Submitted by * Please enter the email of the user submitting the form. Leave this field blank
