General Information
Company Name
*
Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Owner(s) Name
First Name
Last Name
%
% of Ownership
Phone Number
-
Area Code
Phone Number
Owner(s) Name
First Name
Last Name
%
% of Ownership
Phone Number
-
Area Code
Phone Number
Business & Credit Information
Accounts Payable Contact
*
First Name
Last Name
Accounts Payable Phone
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Duns & Bradstreet #
Bank Name
*
Contact
First Name
Last Name
Bank Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Bank Phone Number
*
-
Area Code
Phone Number
Tax Exempt Status (If Yes, Please provide a copy of Certificate of Sales Exemption)
*
Yes
No
Browse Files
Attach Sales Exemption Form
Cancel
of
Requested Credit Terms
*
Ex. 30-Day Terms
Requested Credit Limit
Ex. $1,000
Credit References
Reference 1: Company Name
*
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Type of Account
*
Reference 2: Company Name
*
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Type of Account
*
Agreement
(By checking these boxes you are agreeing to our terms - should you have any questions please contact us)
Terms
*
Invoices are due and payable within 30 days of invoice date. ACH payment is standard payment structure (form provided separately). All claims for defective or damaged goods must be made within three (3) days after receipt of goods. Failure to notify UNITED Medical Supply Company shall constitute acceptance of work, waiver of defect, damage or shortage. A 1.5% service fee will be assessed on past due invoices unpaid after forty-five (45) days from original invoice date. Any changes in these terms must be negotiated in writing with the assigned sales representative. Any requests for extended payment terms must be approved by the UNITED Medical Supply Company corporate office. Customer will be liable for all costs of collection and legal fees incurred by UNITED Medical Supply Company in the enforcement of this Agreement or in the collection of any amounts due and owing UNITED Medical Supply Company from Customer.
Authorization
*
By submitting this credit application, you hereby authorize UNITED Medical Supply Company to make inquires into the banking and business references that you provided.
The undersigned hereby requests open account terms with UNITED Medical Supply Company. In consideration of the extension of credit with your company, I guarantee full and complete payment of account and certify that all information on this application is correct and accurate.
Name
*
First Name
Last Name
Title
Signature
*
Submit
All information herein is the express property of UNITED Medical Supply Company. All disclosed information is for the use of UNITED Medical Supply Company employees only. This document is digitally signed and tracked. All exceptions MUST be approved by UNITED Medical Supply Company management. If you have received this document in error, please immediately contact UNITED Medical Supply Company.
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