Place An Order with Geerpres

Registration Form

If you are not currently registered for on-line purchases, please register HERE:
(* = Required field, must be filled in to submit)

Are you a current Geerpres customer? Yes No If Yes, please enter your Customer # Don't Know
*Company:
Request a Username**:
(**optional: if you do not choose a username, one will be assigned for you)
Request a Password***
(***optional: if you do not choose a password, one will be assigned for you)
*Name:
Title/Dept.:
*Address:
*City:
*State:
*Zip:
*Country:
*Phone:
*Fax:
*E-mail:
*Tax Exempt No.
*Type of Business:
	If Health/Long-Term Care, # of Beds:
	If Federal Government, Federal ID #:
	If Other, please specify:
Buying Group Member:
	If Other, please specify:
Industry Group Memberships:
	If Other, please specify:
Other Purchasing Contact:
Additional Comments:
Enter Promotional Code, if applicable:

Geerpres will issue your company a user ID and password, and notify you as soon as possible so that you may order on-line. If you need immediate assistance, please call our toll free number at (800) 253-0373. Thank you!