FAST SHIPPING & KNOWLEDGEABLE CUSTOMER SERVICE

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

Application Page

    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



    BUSINESS TYPE


    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 [email protected] 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

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    TITLE

    DATE

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    Medical Hose Builder

    COVID-19 update for our customers and business partners Read Here

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