CUSTOMER REGISTRATION

WESTNET, INC.
55 North Street
Canton, MA 02021

Customer Service: 781-828-7772
Fax: 781-828-2011

Email: sales@westnetmed.com

* Required fields

User Information

UserName*

Password*

Billing Information

Facility*

Lab*

Address*

City, State ZIP*

Phone*

Fax

Email*

Accounts Payable
Contact Name*

Shipping Information

Same as billing

Facility*

Lab*

Address*

City, State ZIP*

Phone*

Fax

Shipping Contact Name*:

Purchasing Contact

Same as account payable

Name*

Phone*

Fax

How will you procure product?

If you will regularly use the same credit card please provide

Credit card type

Credit card number

Expiration Date

Name as it appears on card

Card Security Code

What's this?

How did you hear about this site?

If you currently have a Westnet contract number please include your name and account number

Contract Number

Comments/Questions

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