Address Information: COMPANY NAME: STREET ADDRESS: (BILLING) CITY, STATE, ZIP STREET ADDRESS: (SHIP TO) CITY, STATE, ZIP TELEPHONE FAX EMAIL Company Information: YEARS IN BUSINESS FL Dept of Health License Number TAX EXEMPT NoYes (Please include proper documentation) Sole ProprietorshipPartnership Corporation In The State Of BUSINESS TYPE Hospital / Surg CenterDental VeterinaryPlumbing HOW DID YOU HEAR ABOUT US? Referal Contact Information for Individuals / Partners / Corporate Officers Hours of Operation NAME TITLE ADDRESS: ADDRESS: (CONT.) CITY, STATE, ZIP: TELEPHONE: NAME TITLE ADDRESS: ADDRESS: (CONT.) CITY, STATE, ZIP: TELEPHONE: Monday Tuesday Wednesday Thursday Friday Lunch Hours Trade References (For Account Terms & Check Payments) or Credit Card Information COMPANY NAME ADDRESS ADDRESS: (CONT.) CITY, STATE, ZIP TELEPHONE ACCOUNT NUMBER COMPANY NAME ADDRESS ADDRESS: (CONT.) CITY, STATE, ZIP TELEPHONE ACCOUNT NUMBER 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 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. SIGNATURE TITLE DATE
