MED-PART
CREDIT APPLICATION FORM
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Company Information
Company Name *
EIN *
Business Type *
Website
Street Address *
City *
State *
ZIP *
Phone *
Fax
Email *
Sales Tax Exempt *
Yes
No
Billing Information
Billing Contact Name *
Title *
Street Address *
City *
State *
ZIP *
Phone *
Email *
AP Second Contact Name *
Phone
AP Second Email *
Invoice Email (if different)
Shipping Information
Shipping Contact Name
Title
Street Address
City
State
ZIP
Phone
Email
Additional Contacts (Optional)
Role
Name
Phone
Email
Primary
Purchasing
Other
Bank Reference
Bank Name *
Account # *
Bank Contact *
Title
Phone
Email
Trade References *
At least one trade reference is required.
Company Name
Contact Name
Phone
Email
Credit Details
Requested Credit Terms (Days) *
Total Credit Amount Requested *
$
Authorization
I/We certify that the information provided in this credit application is accurate and complete to the best of my/our knowledge. I/We authorize MedPart to verify the information provided and to contact the references listed above.
Authorized Signature *
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Print Name *
Date *
Job Title *
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