New Vendor Request-US

New Vendor Request

Please complete the form to the right, in its entirety in order to receive payment, all sections of the new vendor setup form must be fully completed and submitted.

Attention Vendors:

Please provide your bank information to the right.

New Vendor Request Form >>>

New Vendor Request Form

Are you a Doctor?

Vendor Name

Vendor Address

Vendor City

Vendor State / Province

Vendor Zipcode

Remit Address

Same as Vendor Address

Not the same as Vendor Address

Remit City

Remit State / Province

Remit Zipcode

Contact Name

Contact Phone Number

Fax

Payment Terms

Currency

Payment Type

Bank Name

Upload W-9

Is this vendor a Not for Profit entity?

Allow Optos to contact me?

Yes