Credit Application

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

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-signature
Use 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