New Customer Account Form

Send to:
accounting@gpfinc.com
New Customer Account Form

PLEASE READ THOROUGHLY & COMPLETE EACH SECTION AS REQUIRED
Prices

* All prices are FOB New Port Richey, FL and are subject to change without notice. * All freight charges, including a $5.00 handling fee, will be added to the invoice, and billed accordingly.
Service Charges

* Past due accounts are subject to a 1.5% per month service charge, with an annual effective rate of 18%.
Surcharge Fees

* To cover the cost of processing, we add a 3% surcharge fee to all credit card transactions.
Past Due Accounts

* (1-30) Days Past Due - Discounts and coupons will not be allowed, finance charges will be added, and a phone call will be made. * (31-60) Days Past Due - Discounts and coupons will not be allowed, finance charges will be added, and a phone call will be made. Orders will be placed on "SHIPPING HOLD" (order will be made, however, it will not be shipped until the account is current). After 45 days, we reserve the right to charge the credit card on file for the past due amount(s). *(61-90) Days Past Due - Discounts and coupons will not be allowed, finance charges will be added, and a phone call will be made. The account will be put on "CREDIT HOLD" (orders will not be put into production until the account is current). *(90+) Days Past Due - Discounts and coupons will not be allowed, finance charges will be added, and a phone call will be made. The account will be put on "CREDIT HOLD" and the account may be sent to our attorney/collections. If your account reaches 90+ days past due, you account will be put on COD or Credit Card upon Shipment basis. If your account becomes current and all invoices and finance charges have been paid in full, your account will be re-evaluated. At the Credit Manager's discretion, your account may qualify for credit again after 90 days. *Past due customers will not be released from "SHIPPING HOLD" or "CREDIT HOLD" until we receive payment in full that brings the account current. *We cannot make a shipment based upon a check number or payment promise.
Signature

Clinic Name:
Billing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Office Fax Number:
Please enter a valid fax number.Format: (000) 000-0000.
Main Office Email:
Website:
Shipping Address (if different from billing address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SHIPPING INFORMATION
UPS Ground service is our default shipping method out of Florida. Expedited shipping is available upon request for an additional charge. We do not process shipments on Saturday, Sunday, or any national holiday.

**Please be advised there is a $5.00 handling fee per order that will be added to the invoice and billed accordingly.

Any order completed after 2pm will not be shipped until the next business day.

If you prefer to use your own UPS or FedEx account, please provide us your account # below.
UPS Account #:
FedEx Account #:
PO Required:
Type of Organization (please choose):
FEIN/SS #:
Years in Business
Referred by/How did you find us?
Owner #1 Full Name:

First NameLast Name
Owner #1 Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Owner #1 Email:
example@example.com
Owner #2 Full Name:

First NameLast Name
Owner #2 Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Owner #2 Email:
example@example.com
Accounts Payable Contact Full Name:

First NameLast Name
Accounts Payable Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Accounts Payable Email:
example@example.com
Bank Name:
Bank Account Number:
Bank Contact Full Name:

First NameLast Name
Bank Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Bank Contact Email:
example@example.com
Credit Reference Name #1:
Credit Reference #1 Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Credit Reference #1 Email:
example@example.com
Credit Reference Name #2:
Credit Reference #2 Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Credit Reference #2 Email:
example@example.com
Credit Reference Name #3:
Credit Reference #3 Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Credit Reference #3 Email:
example@example.com

CREDIT CARD INFORMATION
IMPORTANT PLEASE READ!!!

Please fill in your credit card for your account. Orders will not ship without payment information. A credit line may be approved after 60 days of established payment history upon our discretion. The credit card on file will be charged upon shipping, or if an alternate form of payment is refused or returned. Additionally, any outstanding invoices may be charged to the credit card on file if payment is not received within 45 days. We reserve the right to hold orders because of past due invoices.

**PLEASE NOTE TO COVER THE COST OF PROCESSING, WE ADD A 3% SURCHARGE FEE TO ALL CREDIT CARD TRANSACTIONS.
Visa/Mastercard/Amex/Discover Card #:
Exp:
CVC:
Name on Credit Card #:

First NameLast Name
Billing Address for Credit Card:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I certify that all the information on this form is true and accurate. I fully understand and agree to your credit terms of NET 30 DAYS from date of invoice plus finance charges added to any balance not paid after the due date. I authorize Grace Prosthetic Fabrication, Inc. to contact any source necessary (including my bank, credit references and any credit bureaus) to complete an evaluation of my credit and financial history. I agree that I shall assume full responsibility for payment of all legal fees necessitated by default in payment. Suit for collection may be instituted for said balance owed plus interest. I agree that the venue for all actions under this agreement lies in Pasco County, Florida.
Print Full Name:

First NameLast Name
Title:
Signature

GUARANTEE SECTION

Must be completed fully in order to be considered for a line of credit approval. THIS SECTION MUST BE SIGNED BY AN AUTHORIZED CORPORATE OFFICER
Accounts and Payment Terms

Domestic Orders will be shipped COD until credit has been established. Open accounts will be established upon receipt of a completed credit application. Payment terms are NET 30 DAYS from the date of the invoice.
In consideration for Grace Prosthetic Fabrication, Inc. extending credit to the business identified below for any materials and/or services after this date at the request of applicants or its’ agents, the undersigned individual hereby personally guarantees, unconditionally and irrevocably, the prompt payment of all sums now or hereafter owed to Grace Prosthetic Fabrication, Inc. by the business identified below whether said sums are due under open account, contract or otherwise. It is understood and agreed that credit, if extended, is to be on a continuing basis and may exceed the estimated maximum credit limit required as stated in the credit agreement between Grace Prosthetic Fabrication, Inc., and the business. Grace Prosthetic Fabrication, Inc. shall not be obligated to notify the undersigned of the dates or amounts of any such credit and the undersigned waives demand, notice of default and any extension of time or any other forbearance which may be extended by Grace Prosthetic Fabrication, Inc.

This guarantee shall continue in force until notice in writing, sent by registered or certified mail, return receipt requested by Grace Prosthetic Fabrication, Inc. Said notice shall specify the date on which this guarantee is to be terminated. Said date is not to be less than ten days after such notice is received. Such termination shall in no way releases the undersigned as to any sum or debt incurred prior to such termination.
Print Full Name (Individual Guaranteeing Payment):

First NameLast Name
Title:
SSN:
Cell Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Business Whose Account is Guaranteed:
Signature (Individual Guaranteeing Payment):

BLA Account Approved:
Date BLA Account Approved:
Net 30 Day Payment Approved:
Date Net 30 Day Payment Approved:
Credit Card Required:
New Account Report:
Credit Card Report:
Constant Contact:
SharePoint Account:
Shipping Report:
Should be Empty:

New Customer Account Form

Prices

Service Charges

Surcharge Fees

Past Due Accounts

SHIPPING INFORMATION

CREDIT CARD INFORMATION

GUARANTEE SECTION