Page 343 - IM 2017 2018 Full Line Catalog

1810 Summit Commerce Park, Cleveland, Ohio 44087
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1-800-860-8027 or Fax 330-963-0709
Credit Application
Company Name________________________________________________________________________________ Date __________________ Legal Business Name _____________________________________________________________________ State of Incorporation __________ Owner’s/Partner’s/Member’s Name(s) _____________________________________________________________________________________ Business Address ______________________________________ City___________________________State _________ ZIP _______________ Phone ___________________________Fax______________________________Federal Tax I.D. Number ______________________________ D&B # ___________________________Company Website__________________________Line of Credit Requested _____________________ Purchasing Contact _________________________________________________E-mail Address _____________________________________
If above address is a subsidiary, please provide parent company information:
Name (if different than above)________________________________________________________________________ Address______________________________________________ City___________________________State _________ ZIP _______________ Phone ___________________________Fax______________________________
Billing Address __________________________________________ City_________________________State _________ ZIP _______________ Billing Contact ____________________________________ Title ____________________________________________
Phone ___________________________Fax______________________________
A/P Supervisor ____________________________________ Phone___________________________________________
Controller ________________________________________ Phone___________________________________________ Date Present Business Began ________________________ Years At This Address______________________________
Type of Business Home Care Pharmacy Home Health Hospital Other_______________ Type of Ownership Corporation Partnership Sole Proprietor Other _____________________________
Trade Reference
(Please provide at least three medical supply or medical manufacturer references)
Name __________________________________ Phone______________________Fax_____________________ Acct# ___________________ Address ______________________________________________________ City ___________________________ State _____ ZIP ___________
Name __________________________________ Phone______________________Fax_____________________ Acct# ___________________ Address ______________________________________________________ City ___________________________ State _____ ZIP ___________
Name __________________________________ Phone______________________Fax_____________________ Acct# ___________________ Address ______________________________________________________ City ___________________________ State _____ ZIP ___________
Name __________________________________ Phone______________________Fax_____________________ Acct# ___________________ Address ______________________________________________________ City ___________________________ State _____ ZIP ___________
Name __________________________________ Phone______________________Fax_____________________ Acct# ___________________ Address ______________________________________________________ City ___________________________ State _____ ZIP ___________
Please mark which manufacturers you have accounts with for additional trade reference information:
ConvaTec Account # _________________________________ Coloplast Account # _________________________________ Bard® Account # _____________________________________
Bank Reference
Hollister Incorporated Account # __________________________ Johnson & Johnson Account #____________________________ Bayer Healthcare Account # ______________________________
Bank Name______________________________________Bank Contact _____________________________________________________ Account Number _________________________________Phone __________________________Fax ______________________________ Address __________________________________________________________________________________________________________ City ____________________________________________State ___ ZIP _____________________________________________________
(Please complete signatures on reverse side and review Terms and Conditions of Sale).