Customer Information Sheet

This site allows you to request a new Mentor customer account or request updates to your existing Mentor customer account. Please complete the form below. Requests are normally completed within 72 business hours. If the information supplied is incomplete or found to be incorrect, this may delay processing of the application and could affect prompt delivery of products or services. Please note that Mentor reserves the right in its sole discretion to reject any requests for a new customer account or updates to an existing customer account.

Please contact [email protected] if you have any questions.

By registering, you agree that the information you provide will be governed by our Privacy Policy.

Explain Your Request

In as much detail as possible, please explain your request *

e.g., I need to create a new billing account, I need to reactivate my account, I need to change my ship-to address, I need to apply for terms/credit, etc.

Please check the appropriate option(s) to help us fully understand your request. *

Business Information

Business/Practice/Hospital/DBA Name *


Doctor's Full Name *

Doctor's Medical License # *

If hospital, please add "NA" to field.

Doctor's Specialty *

If hospital, please add "NA" to field.

Sales Representative Name


Tax Exempt

If applicable, please attach a copy of your state tax exempt certificate.

Upload or drag files here.

Business Type

e.g., Individual, Partnership, LLC, etc.

State where incorporated *



Subsidiary of

Account Payable Contact Name *


Account Payable Contact Email *

Account Payable Contact Phone *

Billing Account Information

Mentor Billing Account Number

Billing Account Address *


Phone *



Shipping Account Information

Mentor Shipping Account Number

Shipping Account Address *


Phone *




Owner/Partner/Officer Name *

Sign this form by entering your email address and check the below box. Your signature on this form confirms your authorization for Mentor Worldwide LLC to keep this information on file. By signing this form you certify that all information provided is complete and accurate.

Owner/Partner/Officer Email *


Please note that Mentor reserves the right in its sole discretion to reject this credit application and to negate any obligation to proceed with the sale of any Mentor products. In submitting this application for credit, Buyer authorizes Mentor to investigate Buyer’s credit record. Mentor reserves the right to limit the amount of credit extended under this account or terminate the account upon 30 days written notice.