Rhythm Rockstars

Credit Application Form
Please complete in full.
Rhythm Healthcare Contact*
DUNS #*
Company Name*
Phone Number*
Format: (xxx) xxx-xxxx
Fax Number*
Format: (xxx) xxx-xxxx
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Select one*

CorporationPartnershipProprietorshipOther
Year Established*
Sales Tax Number*
(Please include a copy of Sales Tax Certificate)
Please upload the following documents: 1. Sales Tax Exemption Form (if applicable) 2. Articles of Incorporation 3. Audited financial statements 4. Trade reference list 5. Bank References 6. Certificate of General Liability insurance*

Cancelof
Federal Employer ID*
(Please include a copy of Sales Tax Certificate)
Contact Email*
example@example.com
Principle Officer of Company (#1)*

First NameLast Name
Title*
Principle Officer of Company (#2)*

First NameLast Name
Title*
Number of Employees*
Accounts Payable Name*

First NameLast Name
Accounts Payable Contact Email*
example@example.com
Accounts Payable Phone*
Please enter a valid phone number.
Controller/CFO/Owner Business Email*
example@example.com
Controller/CFO/Owner Business Phone*
Please enter a valid phone number.
Credit Limit Requested. Please Specify.*
Percent of Business from DME*
Percent of Business from Respiratory*
Percent of Business from E-Commerce*
Percent of Business from Other*
Bank Reference #1 Full Name*

First NameLast Name
Bank Reference #1 Address*

Street Address

Street Address Line 2

CityState

Zip Code
Bank Reference #1 Account Number*
Bank Reference #2 Full Name*

First NameLast Name
Bank Reference #2 Address*

Street Address

Street Address Line 2

CityState

Zip Code
Bank Reference #2 Account Number*
Trade Reference #1 Full Name

First NameLast Name
Trade Reference #1*

Street Address

Street Address Line 2

CityState

Zip Code
Trade Reference #1 Email*
example@example.com
Trade Reference #1 Account #*
Trade Reference #2 Full Name

First NameLast Name
Trade Reference #2*

Street Address

Street Address Line 2

CityState

Zip Code
Trade Reference #2 Email*
example@example.com
Trade Reference #2 Account #*
Select Shipping Preferences*

Lift Gate RequiredInside Delivery RequiredAppointment Required
Are you a VGM member?*

YesNo
Enter your VMG Member #. Non-members should enter N/A*
Rhythm Healthcare is hereby authorized to obtain credit history information from the above references for the purpose of reviewing for a dealership.
Personal Guarantee
We value transparency and trust in all our partnerships. Signing the Personal Guarantee is a show of good faith and may enhance your standing when seeking higher credit limits or more flexible terms in the future.
I, First Name Last Name , hereby personally guarantee any and all credit extended to my company. I will be personally responsible and liable for all balances due, including costs of collection, should that become necessary.
Credit Application Signature
Title*
Name*

First NameLast Name
Date*

MonthDayYear
Please verify that you are human*
Signature*

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Credit Application Form