customer credit application form and agreement - Medline

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