Register as a Customer

New Customer

Please complete the form to sign up for a wholesaler account.

Facility Name *

Primary Contact First Name *

Primary Contact Last Name *

Company Phone Number *

Email *

Purchase Order is required for order

My facility currently has a contract with Victory Supply

My facility is Tax Exempt

Tax Rate

Address Line 1 *

Address Line 2

City *

State *

Zip *

Country *

Shipping address same as Billing address

Number of Beds

Type of Facility

Do you have questions for us?

How did you hear about us?