BOMInet Home

Sign-Up for a BOMImed Account

Fields with an * are required.

ACCOUNT DETAILS
Username: *
Password: *
Re-type Password: *
	Password criteria: - Minimum 6 characters - At least 1 Upper case letter - At least 1 lower case letter - At least 1 number - At least 1 special character
CONTACT INFORMATION
Contact First Name: *
Contact Last Name: *
Contact Email: *
Phone #:	xxx-xxx-xxxx
Fax #:	xxx-xxx-xxxx
Address: *
City: *
Province: *
Postal Code: *
Country: *
SHIPPING INFORMATION (Default Information for the "Ship To" in the Cart. This can be changed at checkout)
Shipping Address:
Shipping City:
Shipping Province:
Shipping Postal Code:
Shipping Country:
BUSINESS ACCOUNT INFORMATION Complete this section if requesting a credit account. We will contact you to verify your account information.
Organization: *
Occupation Title: *
Customer Account #:
# of Employees:
Finance Contact Name:
Finance Contact Email:
PST Exempt #:
GST Exempt #:
Other Exemption Numbers:	Separate each by a comma
Quote Required:	(Check if you would like a quote before any sale is completed)
P.O Required:	(Check if a P.O Number is required for all purchases)
Credit Limit Request:	$
Authorized Buyers:	Separate each name by a comma
	I have read and accept the Terms of Use