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New Customer Application
COMPANY NAME:
TAX EXEMPT:
NON-TAX EXEMPT:
Items Required with Application
FEDERAL TAX ID:
CONTACT NAME:
If purchasing Rx Product - State or Federal License/Permit
(include with application or send directly to: [email protected])
TELEPHONE:
If U.S. Sales Tax Exempt - Certificate MUST Be Provided
Canadian G.S.T. #
E-MAIL:
BILLING PREFERENCE (check one):
EMAIL ( )
FAX ( )
Canadian P.S.T. #
PLEASE PROVIDE EMAIL or FAX #:
If you are unable to receive invoices via email or fax, please provide Billing address below:
BILLING ADDRESS:
City
State / Prov.
Zip / Postal Code
SHIPPING ADDRESS:
City
State / Prov.
Zip / Postal Code
A/P Contact and Phone Number:
TO MAKE PAYMENTS, VIEW INVOICES OR STATEMENTS ONLINE, PROVIDE EMAIL ADDRESS:
NUMBER OF YEARS IN BUSINESS:
TYPE OF BUSINESS / DESCRIPTION
CORPORATION:
PARTNERSHIP:
NUMBER OF EMPLOYEES:
SOLE-PROPRIETORSHIP:
PARENT COMPANY:
PHONE #
OWNER / PRINCIPAL / GENERAL MGR:
PHONE #
ESTIMATED MONTHLY CHARGES $
To be elegible for credit, estimated charges must exceed $5,000 per month.
YES
DO YOU REQUIRE A PO # ON ALL ORDERS?
ARE YOU USING ANY CONTRACTS?
YES
NO
If YES, please specify below:
NO
PREMIER / AMERINET / NOVATION / BROADLANE / HEALTHTRUST PURCHASING GRP / MEDASSETS / OTHE
BUSINESS REFERENCES
BUSINESS:
Type of Business:
ADDRESS:
CITY / STATE / ZIP:
CONTACT NAME:
PHONE:
BUSINESS:
Type of Business:
ADDRESS:
CITY / STATE / ZIP:
CONTACT NAME:
PHONE:
BUSINESS:
Type of Business:
ADDRESS:
CITY / STATE / ZIP:
CONTACT NAME:
PHONE:
BANK REFERENCE
NAME:
Branch / City / State / Province:
CHECKING ACCOUNT #:
CONTACT NAME:
TELEPHONE / FAX #:
FREIGHT TERMS: PREPAID AND ADDED TO YOUR INVOICE. TERMS CAN ALSO BE FOUND ON OUR INVOICE. ALL PRODUCT IDENTIFIED ON A INVOICE IS
BEING SHIPPINED F.O.B. SELLER'S PLACE OF SHIPMENT. ALL RISK OF LOSS SHALL PASS UPON SELLER'S DELIVERY OF THE PRODUCT TO THE CARRIER.
I hereby authorize the above credit/bank reference(s) to release any appropriate credit information. I/We agree to pay all debts incurred within the terms of sale. I/We further agree to pay collection
costs of past due amounts, including court costs and attorney's fees. Past due amounts are subject to an interest charge of 1 1/2% per month or the highest rate allowable by state law, not to
exceed 1 1/2%.
If approved for credit, terms of sale are NET 30 days from invoice date.
Signature
(Printed Name)
Title
MUST BE SIGNED BY APPLICANT. INDIVIDUAL MUST BE AUTHORIZED TO CONDUCT COMPANY BUSINESS.
Please return completed form to:
Sales Representative:
Laura Sherry
Fax number:
Email:
Telephone:
(858) 345-1745
[email protected]
(858) 704-4022
Date