AI Wellness

Brand Partner Vendor Payment Information

Brand Partner Vendor Payment Information Form

Purpose:

This form is used to collect vendor payment information for equipment purchases, services, sponsorships, commissions, and other approved payments made by AI Wellness Health Management, Inc.

Completion of this form does not authorize payment. Payments will be processed in accordance with the executed partnership agreement, approved purchase orders, and invoice terms.

BILLING INFORMATION

Important Notice

Unless otherwise agreed to in writing, all equipment purchases and invoices for AI Wellness Platinum Network Location Partners shall be billed directly to:

AI Wellness Health Management, Inc.
2080 Century Park East, Suite 1204
Los Angeles, CA 90067

Accounts Payable Email:
team@aiwellness.ai

Phone:
(310) 927-1072

Important
  • All quotations should reference the AI Wellness Platinum Network Location.
  • All invoices should be issued to AI Wellness Health Management, Inc.
  • Purchase Orders, when applicable, will be issued by AI Wellness Health Management, Inc.
  • Do not invoice individual Platinum Network locations unless specifically authorized in writing by AI Wellness Health Management, Inc.
Vendor Billing

COMPANY INFORMATION

Primary Contact Full Name
Primary Contact Full Name
First Name
Last Name
Accounting Contact
Accounting Contact
First Name
Last Name
Company Address
Company Address
City
State/Province
Zip/Postal
Country

TAX INFORMATION

Maximum file size: 268.44MB

PAYMENT METHOD

Preferred Payment Method

BANKING INFORMATION

REMITTANCE INFORMATION

Accounts Receivable Contact Name
Accounts Receivable Contact Name
First Name
Last Name

INVOICE REQUIREMENTS

Please indicate your standard invoicing requirements

PAYMENT TERMS

Standard Payment Terms

SUPPORT CONTACTS

Contact(s) Function
Sales Contact Name
Sales Contact Name
First Name
Last Name
Service / Technical Support Contact Name
Service / Technical Support Contact Name
First Name
Last Name
Shipping / Logistics Contact Name
Shipping / Logistics Contact Name
First Name
Last Name

REQUIRED DOCUMENTS

I am including the following documents (file upload or text input)

Maximum file size: 268.44MB

CERTIFICATION

Confirmation
Authorized Representative Full Legal Name
Authorized Representative Full Legal Name
First Name
Last Name