FAST SHIPPING & KNOWLEDGEABLE CUSTOMER SERVICE

SPEAK TO A MEDICAL GAS SPECIALIST 954-725-1470 | Order History

Application Page

Address Information

Address

Company Information

TAX EXEMPT
Business Type
Referral

Contact Information for Individuals / Partners / Corporate Officers

Address
Address

Hours of Operation

Trade References (For Account Terms & Check Payments) or Credit Card Information

Address

If no trade references are available you may download our credit card authorization form to keep on file for future billing purposes

Once they have completed the credit card form, it should be faxed to 954-725-1168 or emailed to

Download Credit Card Form

Notice

Applicant agrees to pay any collection costs incurred to collect any outstanding balance due, including reasonable attorney’s fees.
A 1 1⁄2 % per month finance charge will be added to invoices not paid within terms.
A $20.00 bank charge will be added to returned checks.

The above information is herewith submitted for the purpose of opening an account and I hereby certify this information to be true.

Medical Hose Builder