Prospective Account Credit Application

Prefer to download a copy of the application and email it to us? Click the button below to download a PDF version of the Account / Credit Application. If you chose this option, please ensure all fields are completed to allow for timely processing of your application!

Email your completed form to Tina

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Account Application Form

Use this form to apply to use the doctor's resources

"*" indicates required fields

Company Information:

Company Name*

DBA

Are you a member of a buying group*

Yes

Name of Group*

Account Number*

Address*

Street Address Address Line 2 City State ZIP / Postal Code Country

Phone*

Fax

Additional Addresses?

Check here if you have additional addresses to add

Address #2*

Street Address Address Line 2 City State ZIP / Postal Code Country

Phone*

Fax

Additional Addresses?

Check here if you have additional addresses to add

Address #3*

Street Address Address Line 2 City State ZIP / Postal Code Country

Phone*

Fax

Additional Addresses?

Check here if you have additional addresses to add

Address #4*

Street Address Address Line 2 City State ZIP / Postal Code Country

Phone*

Fax

Additional Addresses?

Check here if you have additional addresses to add

Address #5*

Street Address Address Line 2 City State ZIP / Postal Code Country

Phone*

Fax

Additional Addresses?

Check here if you have additional addresses to add

Address #6*

Street Address Address Line 2 City State ZIP / Postal Code Country

Phone*

Fax

Business Type (select one)*

Retailer / Private Office

Chain / Private Office

Distributor

Email*

Years in Business*

Please list up to three partners or corporate officers (if available)

Name*

First Last

Title*

Phone*

Additional Partners or Corporate Officers?

Check here if you have an additional partners to add

Second Partner Name*

First Last

Second Partner Title*

Second Partner Phone*

Additional Partners or Corporate Officers?

Check here if you have an additional partners to add

Third Partner Name*

First Last

Third Partner Title*

Third Partner Phone*

Person to contact regarding purchase orders and invoice payments

Name*

First Last

Title*

Address*

Street Address Address Line 2 City State ZIP / Postal Code Country

Please provide up to two bank references

Bank Name*

Bank Address*

Street Address Address Line 2 City State ZIP / Postal Code Country

Account Number*

Bank Contact Name*

First Last

Bank Contact Phone*

Additional Bank Reference?

Check here if you have an bank reference to add

Second Bank Name*

Second Bank Address*

Street Address Address Line 2 City State ZIP / Postal Code Country

Second Account Number*

Second Bank Contact Name*

First Last

Second Bank Contact Phone*

Please provide two trade references

Trade Reference Name (Reference #1)*

Trade Reference Address*

Street Address Address Line 2 City State ZIP / Postal Code Country

Account Number*

Trade Reference Contact Name*

First Last

Trade Reference Contact Phone*

Trade Reference Name (Reference #2)*

Trade Reference Address*

Street Address Address Line 2 City State ZIP / Postal Code Country

Account Number*

Trade Reference Contact Name*

First Last

Trade Reference Contact Phone*

Signature

Owner / Officer Name*

First Last

Title*

Date*

EIN (Tax ID Number)*

Prospective Account Credit Application

Account Application Form

Company Information:

Please list up to three partners or corporate officers (if available)

Person to contact regarding purchase orders and invoice payments

Please provide up to two bank references

Please provide two trade references

Signature

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