NEW CUSTOMER APPLICATION

All Things DME, LLC
870 S 860 E, Suite 300
American Fork, UT 84003
NEW CUSTOMER APPLICATION
Applicant hereby applies for credit in accordance with the terms and conditions of All Things DME, LLC
Please complete and sign both the New Customer Application form and the Sales & Use Tax-Exempt forms, if not applicable indicate on the form, then return signed form. If using your company's standard credit information sheet, please make sure that all information requested is either on your form or included in the New Customer Application. Accounts will not be set up until all information is received complete and signed.
COMPANY INFORMATION
Name:
Years Established:
Federal EIN:
DUNS #:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Fax:
Billing Email:
example@example.com
Type of Business:
Parent Corporation:
Name of Principals or Officers:
CREDIT REFERENCES
1. Company Name:
Account Number:
Contact:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Fax:
Page 1 of 5

All Things DME, LLC
870 S 860 E, Suite 300
American Fork, UT 84003
2. Company Name:
Account Number:
Contact:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Fax:
3. Company Name:
Account Number:
Contact:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Fax:
BANK REFERENCES
1. Bank Name:
Contact:
Number of Years:
Account Number:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Fax:
2. Bank Name:
Contact:
Account Number:
Number of Years:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Fax:
Page 2 of 5

All Things DME, LLC
870 S 860 E, Suite 300
American Fork, UT 84003
GENERAL INFORMATION
Credit Limit Requested $:
Anticipated Monthly Volume $:
Accounts Payable Contact:
Purchasing Contact:
AGREEMENT
1. Upon approval of this application, an account will be opened for you (Buyer) by All Things DME (Seller) with Net 30-day terms.
2. Buyer understands & agrees that goods purchased hereunder (the Products) are subject to a 20% restocking fee. Minimum order is $100.00.
3. If failure to pay according to the terms of the AGREEMENT causes this account to be assigned or referred to an attorney for collection, Buyer agrees to pay Seller's reasonable collection and/or attorney fees, all court costs, and NSF fees; if applicable, to the extent permitted by law.
4. Seller is authorized to investigate Buyer's credit record. Seller is authorized to report Buyer's performance on this agreement to proper persons and credit agencies whenever Buyer gives Seller's name as credit references.
5. In order to protect Seller in the event of a default by Buyer, Buyer, as debtor, hereby grants to Seller, a purchase money security interest in the goods to be purchased hereunder and shall execute as debtor upon request of Seller as secured party, from time to time such financing statements or other documents as may be deemed necessary or appropriate by Seller to perfect or protect its security interest hereby created.
6. In the event of a conflict between Buyer & Seller pursuant to this application for credit or the purchase of goods and services hereunder, Buyer and Seller agree that (a) any actions or claims brought shall be governed by the law of the State of Utah, without regard to its choice of law rules, and (b) such action or claim shall be brought in the State of Utah.
The Undersigned hereby certifies that he or she is duly authorized to sign this application on behalf of the Applicant/Buyer, that the information given in this application is true and correct to the best of his or her knowledge and that the Applicant/Buyer hereby agrees to the foregoing terms and conditions.
AUTHORIZATION
X Signature of Owner or Company Officer
Print Name
Date

MonthDayYear
Date
Title
Phone:
Format: (000) 000-0000.
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All Things DME, LLC
870 S 860 E, Suite 300
American Fork, UT 84003
SALES & USE TAX EXEMPT FORM
(Please include a copy of your Sales and Use Tax Exemption Certificate)
Company Name:
Billing Address:
City:
State:
Zip:
Phone:
Format: (000) 000-0000.
Fax
I HEREBY CERTIFY that I hold a valid Seller's Permit/Resale Certificate and the tax number is:
Issued pursuant to the Sales and Use Tax Law; that I am engaged in the business of selling:
That the tangible personal property described herein which I shall purchase from All Things DME, LLC will be resoldby me in the form of personal property; provided, however, that in the event any such property is used for anypurpose other than retention, demonstration, or display while holding it for sale in the regular course of business, it isunderstood that I am required by the Sales and Use Tax Law to report and pay for the tax, measured by the purchaseprice of such property.
Description of property to be purchased
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All Things DME, LLC
870 S 860 E, Suite 300
American Fork, UT 84003
AUTHORIZATION
Signature of Owner or Company Officer
Date

MonthDayYear
Date
Print Name
Title:
Phone:
Format: (000) 000-0000.
Fax: 801-762-6556
Phone: 801-692-0923
Website: allthingsdme.com
Email: orders@allthingsdme.com
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Should be Empty:

NEW CUSTOMER APPLICATION

COMPANY INFORMATION

CREDIT REFERENCES

BANK REFERENCES

GENERAL INFORMATION

AGREEMENT

AUTHORIZATION

SALES & USE TAX EXEMPT FORM

(Please include a copy of your Sales and Use Tax Exemption Certificate)