Customer Credit Application

Customer Credit Application
Date

MonthDayYear
Date
Type of Business
(Physician - Occupational Health - R & D Clinics-Schools - Universities - Government - Resellers - Drop Ship - Urgent Care - Personal Care - Veterinarians - Other)
Federal Tax ID# or SS#
Year Established
Name of Ownership Corporation
Facility Name
Billing To Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Accounts Payable Contact

First NameLast Name
Phone
Format: (000) 000-0000.
Email
example@example.com
Does Your Company Require Purchase order Numbers?
Bank Reference
Date Opened

MonthDayYear
Account #(s)
Bank Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact at Bank

First NameLast Name
Bank Phone#
Format: (000) 000-0000.
Trade References

(Important to include full information)
Firm Name
Contact Phone #
Account Number
Firm Name
Contact Phone #
Account Number
Firm Name
Contact Phone #
Account Number
Firm Name
Contact Phone #
Account Number
Licensing: Valid State License AND a DEA License (if applicable) must be included with application.

Pending Credit Approval Terms: Credit Card, Check in Advance or C.O.D.

The undersigned hereby agrees that if a credit account is opened, payment is expected no later than 30 days from the invoice date. In the event of default in payment due and a collection authority is needed, additional charges will be charged equal to the cost of collection including court costs.
Signature
Printed Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Customer Credit Application

Trade References