* If Unknown, Please Fill in Details Below

INVACARE Webshop Completed by : Access Request Date : Customer number* :...... * If unknown, please fill in details below

Company Name :...... Address: ...... Address :...... Address :...... Town/City : ...... Postcode:...... One account must be created for each person using our webshop Don’t forget that the security of our system is based on the attention you pay to filling in this form! Account 1 First name : ...... Last name :...... Email address (used to receive order acknowledgements) :...... Password required (maximum 25 chars – no minimum) :...... Account expiration date (YYYY/MM/DD or unlimited) :......

This user can fill a cart and place an order This user is not allowed to place orders (can only fill carts) Phone* : ...... Fax* :...... Mobile phone* :...... * optional details Account 2 First name : ...... Last name :...... Email address (used to receive order acknowledgements) :...... Password required (maximum 25 chars – no minimum) :...... Account expiration date (YYYY/MM/DD or unlimited) :......

This user can fill a cart and place an order This user is not allowed to place orders (can only fill carts) Phone* : ...... Fax* :...... Mobile phone* :...... * optional details Account 3 First name : ...... Last name :...... Email address (used to received order acknowledgements) :...... Password required (maximum 25 chars – no minimum) :...... Account expiration date (YYYY/MM/DD or unlimited) :...... This user can fill a cart and place an order This user is not allowed to place orders (can only fill carts) Phone* : ...... Fax* :...... Mobile phone* :...... * optional details

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