customer credit application form and agreement - Medline

MedCal Sales LLC 3350 Shelby Street, Suite 200 Ontario, CA 91764CUSTOMER CREDIT APPLICATION FORM AND AGREEMENTNote:In order to expedite the establishment of your new account with MedCal Sales LLC, (Medline), it isimperative that each section of this 3-page application be completed. Once completed and signed, youmay choose to fax the application to (847) 837-2765.Medline Sales Representative nameI. OWNERSHIP INFORMATION: Identify Corporate Entity, DBA, and/or principle owner(s). If there aremultiple owners please attach a complete list including the names, address and the percentage ofownership. If you have a Parent company, please list under company name.Registered Company NameDoing Business As _________________________________________________________________________Address City State Zip____Phone - - Fax Number: - -Name of Owner/ Senior Financial OfficerPercent OwnedTitleSS#Phone Fax Number _____Partnership ____ Corporation Sole Proprietor_____ Publicly Traded_ ___ Duns NumberNBR of Employees ______ NBR of Facilities ________NBR of Beds _______ Yrs in Business ___________Owned Property ____ Leased Property ____ Name of Lessor _______________________ Phone ___________II.BILL TO CUSTOMER INFORMATION: complete if different from above (Invoices will be sent to this address)Company NameAddress _____________ City St ZipAccount Payable Phone _____ A/P Fax Number A/P Contact Name:Email address: ___________________________________________A. SHIP TO LOCATION(s) Applicant assumes financial responsibility for amounts due and owing to Medline.For multiple locations please attach a facility listing including the phone/fax information and the contact person’s name.Complete if different from aboveFacility Name(s)Address _________ City St ZipPhone Contact Person ___________State Tax Status: State Resale Number ________ Tax Exempt/Not for Profit* Taxable/For Profit _____Federal ID Number ________ ____ (You will be charged State SalesTax)*For Tax Exempt, or Resale Status, a valid tax-exempt certificate for each ship to location is required beforean account can be established.1

By signing this form the Applicant agrees to be responsible for all invoices and for shipments to all of the facilities listedon the attached sheet. Medline requires a separate credit application for each facility for which the applicant is notresponsible.III. MANAGEMENT COMPANY / THIRD PARTY PAYERPlease Complete this section if another organization managesyour payments.Company Name(s)Address _________ City St ZipPhone Contact Person ___________Yrs in Business NBR of Managed Facilities (Provide listing of managed entities)IV.GENERAL INFORMATION - BUSINESS TYPEAssisted Living Center Home Health Agency Laundry State, County, or Federal FacilityDealer Hospice Nursing Home Surgery CenterDental Office Hospital Physician OfficeDialysis Center Insurance Carrier PharmacyOther: (Explain) ______________________________________________Annual Revenues $ Requested Credit Limit $(Please indicate the dollar volume of credit desired)Are you part of a buying group? ___ Group Name__________What Portion of your revenue is dependent on Government or State funding such as Medicare, Medicaid, etc. %Are there related accounts currently doing business with Medline that we should consider when reviewing your application?Has the applicant or any of its owners or managers ever operated the same business under a different name?If Yes, Company NameMedline Acct NumberAddress __________ City St ZipV. FINANCIAL INFORMATION : Trade References:1. Name Phone Contact Name ________________ High Credit _____________Address City ST Zip ____Currently Owe ___________2. Name Phone Contact Name _________________High Credit _____________Address City ST Zip ____Currently Owe ___________Note: Attached Bank Release Authorization form must be completed or Terms will default to Cash In AdvanceTerms: By signing this form the Applicant agrees to pay all invoices for shipments to all of the facilities listed on the above sheet. Medline requires aseparate credit application for each facility for which the applicant is not financially responsible. Invoices are due and payable within 30 days of invoicedate. Proof of delivery must be requested within 30 days of shipment date on all normal delivery, express delivery must be requested within 10 days ofshipment date. Service charges of 1 ½% per month, or as allowed by law will be assessed on all balances outstanding past specified credit terms. Anyrequests for extended payment terms must be approved by Medline corporate Credit Department. Customer consents to the jurisdiction of any state orfederal court in Lake or Cook County, State of Illinois. Customer will be liable for reasonable costs and legal fees incurred by Medline Industries toassist in the recovery of any receivables in default.BY COMPLETING AND RETURNING THIS APPLICATION TO MEDLINE, THE APPLICANT REPRESENTS THAT ALL OF THE INFORMATION CONTAINED IN THISAPPLICATION IS TRUE AND CORRECT AND APPLICANT AGREES THAT IF ANY OF THE INFORMAITON BECOMES OUTDATED OR IF APPLICANT LEARNS OF APOSSIBLE OR PENDING CHANGE IN OWNERSHIP OR MANAGEMENT OF IT OR ANY FACILITY, IT WILL IMMEDIATELY NOTIFY MEDLINE.FOR APPLICANTBy:Title:(Print name)Signature: _____________________________________________________Date:2

Bank Reference Information: Main Operating AccountName: Phone: Fax:Address: City ST ZipContact Name:Email Address: _________________________________________Authorization to Release Credit InformationCompany Name(s) as appears on the Bank Account:I(Must be authorized signer for account)hereby authorize(Name of Bank)to release credit information to MEDCAL SALES LLC (MEDLINE) for the purpose of establishing credit on thisday of , 20 .Please, release credit information, using the form provided, on the following account type(s):Checking Account #Savings Account #Line(s) of Credit Account #Other Account #Please Sign Here:Date:(Person signing release form must be the authorized signer for the account(s).)All information received is strictly confidential and is for Medline’s use only.3

MEDLINE RETURN GOODS POLICYThis Policy applies unless you have a contract providing terms. Wereserve the right to reject any Return that does not comply with theterms of this Policy. Returns of non-Medline brand items and “vendordirects” are subject to the terms and conditions of the manufacturer and may be at customer’sexpense.Custom Items, Patient Home Direct, Kaumographed and Embroidered Textiles, are not returnable.However we will accept a Return of any item for full credit if we shipped in error or if the item isdefective or damaged. All other discretionary Returns are subject to a restocking fee (see below).Authorization and a Returned Goods Authorization Number (RGA) are required for all Returns andmay be obtained by calling Medline’s Return Goods Department at 1-800-307-8386. An RGANumber is valid for 60 days after issuance. Any Return after the 60 day period has expired is notauthorized and will not be issued credit.Returns may be rejected because of the physical condition of the items. Specifically: (a) only items infull, complete and unopened cases with original packaging are returnable, (b) items with “piggybacklabels” on the packaging are not returnable, (c) nutrients are returnable only if returned more than sixmonths before their expiration date, (d) expired items are not returnable, and (e) items otherwise inan unsalable condition due to improper storage, spoilage, or damaged packaging are not returnable.If a Return is for your convenience (in other words, not the result of Medline’s error, defect ordamage), then you will be charged a restocking fee based on the number of days that elapsed sinceinvoice date:Return from Date of InvoiceFee as a % of the Invoice Amount0 - 30 days 0% + Freight31 - 60 days 10% + Freight61 - 120 days 20% + Freight121 - 180 days 30% + Freight6 months or greater not returnableCustomer will not be charged freight on Returns that are the result of Medline error, defect ordamage. In all other situations (i.e.: a discretionary return on your part, your error, overstock atyour facility), Customer will be responsible for pre-paying freight charges unless Medline issues calltags or a bill of lading. (freight charges will be deducted from the credit amount).Revised 6/10/03