Multiple Location Form

Please complete this form if you are an HME Provider and have multiple locations.

Your original member registration and primary contact person will always be Location #1.
Number all additional locations accordingly.

After you submit location #2 you will have the option to enter additional locations.

Please enter the primary company name (company name listed as Location #1).
Primary Company Name *
Enter the location number with your primary company being Location #1. (i.e. #2, #3, #4, etc.)
Additional Location Number *
Complete if different from the Primary Company Name.
Company Name of Additional Location
Enter name of the contact person at this additional location.
First Name *
Middle Name
Last Name *
Enter the address of Location #2.
Address *
City *
State *
ZIP *
Phone *
Toll Free
Fax
While this field is not required for additional locations, it is a very important communication tool to our members.
Email
Website



 

Illinois Association for Medical Equipment Services
1601 N Bond Street, Suite 303 • Naperville, IL  60563
Ph: 630.369.7782 • Fax: 630.369.3773
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