Domestic Credit Application & Medical Device Agreement

Domestic Credit Application & Medical Device Agreement
Your privacy is important to us. We take all necessary precautions to ensure the security of your financial and personal data.We use industry-standard encryption protocols to safeguard your information during transmission and storage. All data submitted through this form is encrypted using 256-bit SSL (Secure Socket Layer) technology.
Company Firm Name:*
D.B.A:*
Billing Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Shipping Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number:*
Please enter a valid phone number.
Fax #:
Preferred Shipper:*
Account:*
Purchasing Contact:*
Billing Contact:*
E.I.N. #:*
State Resale, Exemption or 501(c)(3)#. (Attach Copy):*
State Resale, Exemption or 501(c)(3) File Upload:*

Cancelof
Payment Method:*

WireACHCheckCredit Card
Bank Reference:*
Account #:*
Bank Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Bank Phone:*
Please enter a valid phone number.

Trade References
Company:*
Reference 1
Contact:*

First Name Ref1Last Name Ref1
Phone Number:*
Enter a valid phone number for Reference 1
Email:*
Ref1: example@example.com
Company:
Reference 2
Contact:

First Name Ref2Last Name Ref2
Phone Number:
Enter a valid phone number for Reference 2
Email:
Ref2: example@example.com
Company:
Reference 3
Contact:

First Name Ref3Last Name Ref3
Phone Number:
Enter a valid phone number for Reference 3
Email:
Ref3: example@example.com

Applicant agrees that the above information is true to the best of applicant’s knowledge. Applicant agrees to pay all invoices for goods sold to it from Sleepnet Corporation at the prices established by Sleepnet on the basis of net thirty (30) day terms, and any finance charges, based on the maximum limit permitted by law, assessed on the unpaid balance due if not paid within terms.

Applicant agrees to be responsible for providing a clear path of traceability, not to alter the product and to only distribute it in countries where it can be legally marketed. Applicant agrees to record notification of complaints, anomalies, mishaps and failures associated directly or indirectly, or suspected as such by the complainant, which involve the Product. The Applicant agrees to record the lot number of all Products and the distribution destination. Further, in the event of a corrective action such as, but not limited to, product recall, voluntary withdrawal or user advisory, the Applicant shall provide complete and accurate records of recipients of implicated lots, or reproduce and distribute notification of the action on behalf of Sleepnet. The Applicant agrees to maintain records for no less than five (5) years after the creation of the record
Applicant's Signature:*

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Title:*
Printed Name:*

First NameLast Name
Date Signed:*

MonthDayYear
Date
*****APPLICATIONS WILL NOT BE PROCESSED WITHOUT SIGNATURE*****
Sleepnet Use Only: (Do not fill out the below fields)
Sales:
Finance:
Date:
Business Type:
Sleepnet Corporation | 5 Merrill Industrial Drive | Hampton | NH | 03842 | 1-800-742-3646 | www.sleepnetcorp.com
| Email: orders@sleepnetcorp.com | Sales: 603-758-6624 | Fax: 603-758-6699
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Domestic Credit Application & Medical Device Agreement

Trade References