Application Page

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 orders@medicalgassupplier.com to complete the application process

Download Credit Card Form

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.