<!-- -->

Create a New Account

    YESNO   if yes, tax exempt #:

    (Please include a copy of your tax-exempt certificate)

    Trade Credit References

















    I , authorize ContourMD Marketing Group LLC to charge my credit card for
    agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.

    ContourMD Marketing Group l 15550 W. 109th Street l Lene xa, Kansas 66219 l Phone 1.800.331.6990 l Fax 913.541.0380
    ContourMDmarketing.com – Company Website l ContourMD.com – Online Recovery Center

    <!-- -->
    Trust Guard Security Scanned