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All fields with * are required.
Attention:   A minimum of $25 for US orders and $250 for international orders is required.
Important:  Please make sure that your telephone number and e-mail address are both correct. We may need to contact you to confirm the information provided in this application.
**A credit check is required to establish a Net 30 account.
We cannot ship to P.O. Boxes and PMB (Private Mail Boxes), Hotels/Motels.
Business Name
* Full Name
Billing Address
* Address
Suite/Apt/Unit Please write if it is Suite #, Apt #, Unit #, etc. (ex: Suite # 24)
* City, * State, * Zip
* Country
* Phone, Fax
* E-mail Make sure to enter your correct email, since we will inform you through email.
Shipping Address
"Please Note: We will not ship to P.O. Boxes and PMB (Private Mail Boxes), Hotels/Motels."
* Contact Name
Check here if the Shipping address is the same as Billing address
* Shipping Address
Suite/Apt/Unit Please write if it is Suite #, Apt #, Unit #, etc. (ex: Suite # 24)
* City, * State, * Zip
* Shipping Country
* Phone
Credit Information
* Social Security No.
* Tax ID #
* Driver's Lic #   St. 
Type of Business
    Proprietorship    Partnership    Corporation/LLC
  Tax Exemption    PC
  Other  
Important Information
Due to State and Federal laws: Prior to your first purchase of any controlled substances (IE: Needles, Syringes, Anesthetics, I.V. solutions, Injectable, etc.), please fax and/or mail us a copy of the Doctor's license and DEA number for our records.
* State License   Exp. Date 
* D.E.A. Number   Exp. Date 
Bank Information
Bank Name
Branch #
Account #
Account type
Bank Address
City, State, Zip
Bank Country
Phone, Fax
Contact name
Preferred Method of Payment
    Net 30 Days    Credit Card
  C.O.D.
**If you are requesting a "Net 30" Account
(please type in capital "YES"), I authorize Pearson to request consumer reports from consumer reporting agencies to be used in considering this application. I have also read and agree to the terms & conditions at the bottom of this page.
**Corporate Accounts: Your account will not be established as a Corporate Account unless we receive your completed Corporate Application, Agreement and Guaranty.
**C.O.D. Orders: The limit for company check is $250.00. All orders over $250 must be paid with a cashier's check or money order. (No personal check). C.O.D. orders include a $11.00 charge, plus the shipping charge per shipment."
Credit Card Information
Credit holder Name Your Name as it shows on the card.
Credit Card # Do not use spaces or "-". EX: 4567334477889900
Card Verification No.
(On the back of your card, find the last 3 digits)
Need help finding your Card Verification Number?
Using American Express?
Credit Card Type
Card Exp. Date
Password for Online Access
Select a password to access Pearson Website.
Try to select a strong password that will be easy for you to remember.
Do not use any special characters such as (~!@#$%^&*+?/':;").
* Password
NOTE: For fraud protection purposes, Pearson Dental reserves the right to verify orders through a variety of means such as phone and license verification, request for copies of front and back of the credit card and a valid identification.
Pearson Dental reserves the right to cancel any orders and void or credit any corresponding credit card transactions that it is unable to validate.
  Checking this box authorizes Pearson Dental to charge this credit card at time of each purchase.
International Orders Terms & Conditions:
The following terms and conditions apply to the exportation of the shipment of your order:
  • A minimum order of $250 is required for the Internet Orders Outside of the United States.
  • Pearson Dental is not liable for the shipment of your order once it is released to the Transportation Carrier.
  • The customer is obligated to study the rules and regulations of the destined country for importing of Dental/Medical Merchandise, and is also responsible in clearing the shipment with their own customs broker, pay all related fees (i.e. clearance, duties, taxes and all other fees relating to the clearance of shipment in their respective country). These charges are recipient's responsibility.
  • Shipping & Insurance fees: Shipments to other countries will be made through FEDEX, UPS or USPS (US Mail). Freight charges on International orders depend on carrier, the weight and measurement of the packages. Your freight charge will be the exact amount charged by the carrier.
  • Additional Insurance: As some of the carriers do not insure the total value of the content of the packages shipped international, we automatically add third party insurance to cover the lost and damaged goods in the shipment. This additional insurance fee will be added to your freight charge.
    Buyer will be responsible for Shipping charges plus shipping insurance and/or the additional 3rd party insurance fees.
    ** If your shipping address is outside of the United States, by clicking the SUBMIT FORM button, you agree to the International Orders Terms & Conditions above.

  • Terms and Conditions:  By clicking the SUBMIT FORM button, you give Pearson Dental Supply Company permission to request consumer reports from consumer reporting agencies to be used in considering this Application and subsequently for the purpose of any update, renewal, extension of credit, reviewing or collecting on the account. Upon your written request, we will inform you of the name and address of each consumer reporting agency from which we obtain a consumer report relating to you. Proprietorships, Partnerships, or Corporations including professional corporations assume liability for ALL purchases made by any employee, manager, office, doctor, or pharmacist employed when the order was placed. I hereby agree to pay interest on all overdue accounts at the rate of 1.5% monthly, and to pay all costs of collection including reasonable attorney's fees. I hereby certify that the information set forth above, together with all other information submitted in connection with this application, is true and correct.
    NOTE: Please be advised that it will take a minimum of 24 business hours to open a new account.
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