Filter - Med-Dyne

Credit Application
I, (we) submit the following information in applying for an open account:
1-877-MED-DYNE (633-3963) Phone sales@med-dyne.com Email 502-429-6759 Fax
www.med-dyne.com
Business Name ______________________________________ Type of Business ______________________________________
Address ____________________________________________ Shipping Address ______________________________________
City __________________ State ________ Zip ____________ City ____________________ State ________ Zip __________
Phone Number ( )________________________________ Phone Number ( ) ________________________________
Fax Number ( )________________________________ Fax Number ( ) ________________________________
Accounts Payable Contact ______________________________________________________________________________________
COMPLETE APPLICABLE SECTION:
Individual Partnership Corporation Subsidiary of
Owner’s. Officer’s Director’s or Partner’s Names:
1. __________________________ Address ____________________ City ____________________ State ____ Zip__________
2. __________________________ Address ____________________ City ____________________ State ____ Zip__________
Year Incorporated ______________ State ______________________ Year in Business __________________________________
Owner’s Social Security __________________________________
PERSONAL GUARANTEE: In consideration for credit extended, the undersigned individual contracts and guarantees to faithful payment, when due, of all accounts of the
company seeking credit under this application. The undersigned guarantor expressly waives all notice of acceptance of this guarantee, notice of extension of credit, presenting
of demand for payment and any notice of default by the company seeking credit and all other notices the guarantor might be entitled to.
Name ______________________________________________ Date ______________
Business Name ____________________________________________ Checking Account # ______________________________
Address __________________________________________________ Savings Account # ______________________________
City ________________________________State______ Zip____________ Phone Number ( ) __________________________
TRADE (1) ____________________________________________ Acct. # ______________________________________________
Address ____________________________ City ______________ State______ Zip __________ Tel. # ( ) ________________
TRADE (2) ____________________________________________ Acct. # ______________________________________________
Address ____________________________ City ______________ State______ Zip __________ Tel. # ( ) ________________
TRADE (3) ____________________________________________ Acct. # ______________________________________________
Address ____________________________ City ______________ State______ Zip __________ Tel. # ( ) ________________
I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND AGREE TO THE ABOVE SHOWN.
SIGNATURE OF OWNER/PARTNER OR OFFICER DATE
AUTHORIZED SIGNATURE OTHER THAN ABOVE DATE
Med-Dyne
TERMS: Credit Terms are 30 Days from date of invoice. Outstanding balances are subject to 1.5% per month interest. The undersigned authorizes and releases all banks,
persons and companies listed on this application. The undersigned agrees to pay all collection costs and legal fees incurred to collect delinquent balances.
FIRM NAME: ________________________________________________________________________________________________________________________________
I HEREBY CERTIFY, That I hold valid seller’s permit Number: ________________________________________________________________________________________
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 WILL BE RESOLD BY ME IN THE FORM OF TANGIBLE PERSONAL PROPERTY; PROVIDED,
HOWEVER THAT IN THE EVENT ANY SUCH PROPERTY IS USED FOR ANY PURPOSE OTHER THAN RETENTION, DEMONSTRATION OR DISPLAY WHILE HOLDING IT FOR SALE IN THE
REGULAR COURSE OF BUSINESS, IT IS UNDERSTOOD THAT I AM REQUIRED BY SALES AND USE TAX LAW TO REPORT AND PAY FOR THE TAX, MEASURED BY THE PURCHASE PRICE OF
SUCH PROPERTY.
Description of property purchased ________________________________________________________________________________
Date ______________ 20 ____ Purchaser: ________________________________________________________________________
By and Title: ____________________________________________________________ Telephone # ( ) __________________
Address ______________________________________________ City______________ State ______ Zip ____________________
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