Alpha Source Web Account Registration

We're happy you have chosen Alpha Source to be your source for medical products and supplies. Our easy account set up will get you on track to making fast, secure purchases of quality medical products. Having an Alpha Source web account will simplify the ordering process. Once your account is set up by our Customer Service department, you will be able to view order history, your special pricing, track shipping and more. Sign up now by filling out the simple form below!

Instructions:

To register for a customer account on the Alpha Source website, enter the requested information in the form below. Required fields are marked with an asterisk (*); your Username and Password must each be at least 4 characters long.

Contact Information:
Name: *
Title:
E-mail: *
Phone: *
Fax:


Account Details:

1. Is this a GSA account?
 Yes   No

2. Will you be making purchases for an organization that has ordered from Alpha Source in the past?
 Yes   No

If yes, please enter your organization's customer number, or leave blank if you don't know it.
Customer # 

3. Is your organization a part of a Hospital Buying Group? Select one from this list:


If yes or Other, please list any supporting details.
(e.g. Premier - Entity Code:XXXXXX)


4. How did you hear about Alpha Source?


Login Options:
Username (30 characters max): *
Password (15 characters max): *
Re-enter Password (15 characters max): *

Billing Address:
Company: *
Address: *


City: *
State: *
Zip: *
Resale Certificate:
Resale Certificate Number:

If you are tax-exempt, please contact Customer Service at 1-800-654-9845 to place your first order. As required by law, you will need to provide a tax exemption certificate.