Credit Application Please fill out information below and click “Send”. Fields with (*) are required. Business Contact Information Legal Company Name* Date Business Commenced d/b/a Street Address City, State, ZIP Code Phone Number* Fax Number Email* Website Business Type CorporationSole ProprietorshipPartnershipOther Business and Credit Information Estimated Annual Sales Bank Name Expected Monthly Credit Requirement Primary Business Address Federal ID # Phone D&B # (if applicable) Account Number Type of Account SavingsCheckingOther Business/Trade References Company Name Contact Name Address City, State, ZIP Code Phone Fax Email Current Payment Terms 1 2 3 Agreement 1. All invoices are to be paid 30 days from the date of the invoice. 2. Applicant agrees to pay a monthly service charge of 1.5%, annual rate of 18%, if charged, applied to all balances over 30 days old. 3. Should it become necessary to place the account with a collection agency or attorney, applicant agrees to pay all collection costs and attorney fees in addition to all other sums due. 4. Claims arising from invoices must be made within seven working days. 5. BMP Medical reverses the right to withdraw credit at any time and at its sole discretion. 6. By submitting this application, you authorize BMP Medical to make inquiries into the banking and business/trade references that you have supplied. Name of the individual that filled out the application: Date E-signatureUse your mouse to sign your name in the box below Additional Information Purchasing Contact Purchasing Phone | Fax Purchasing Email Accounts Payable Contact Accounts Payable Phone | Fax Accounts Payable Email Method of Invoice Delivery ElectronicallyUS Mail Email for Electronic Delivery of Invoices Billing and Shipping Information Billing Address Billing Street Address Billing City, State, ZIP Code Preferred Shipping Method Carrier Account Number Preferred Shipping Address Shipping Street Address Shipping City, State, ZIP Code Alternate Shipping Address Alternate Street Address Alternate City, State, ZIP Code