Credit Application - BMP-medical

Business Contact Information

Is your order size more than $10,000?

Yes

No

Legal Company Name*

Date Business Commenced*

D/B/A

Street Address

City, State, ZIP Code

Phone*

Fax Number

Email

Website*

Business Type

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

Agreement

All invoices are to be paid 30 days from the date of the invoice.
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.
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.
Claims arising from invoices must be made within seven working days.
BMP Medical reserves the right to withdraw credit at any time and at its sole discretion.
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

Additional Information

Purchasing Contact

Purchasing Phone

Purchasing Email

Accounts Payable Contact

Accounts Payable Phone

Accounts Payable Email

D&B # (if applicable)

Account Number

Method of Invoice Delivery

Email for Electronic Delivery of Invoices

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