U.S. Federal Government Contracts


Please note: All fields marked with a ( * ) are required.

Company Information
* Company Name:
* Company Address:
Company Address 2:  
* City:
* State/Province:
* Postal Code:
* Country:

Individual Access Information
* First Name:
Middle Name:
* Last Name:
Title:
Department:
* Phone::
(in the format 123 456 7890)
Customer Fax:
(in the format 123 456 7890)
* Primary Email:
Secondary Email:
Customer Number(s):
e.g. 123456,234567,345678

Authorization
  I am an authorized officer or other authorized employee of the Company named above, and request that Carestream Health provide me with access to the Carestream Health Partner Site on behalf of the Company named above. Customer acknowledges that all use of the Partner Site will be subject to the Carestream Health Partner Site Operating Guidelines; a copy of which will be provided at the time the initial online account is established. Submission of this form constitutes authorization.