Application Page Address InformationCompany Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code FAX Email Company InformationYears in Business FL Dept of Health License Number TAX EXEMPT No Yes (Please include proper documentation) Sole Proprietorship Partnership Corporation In The State Of Business Type Hospital / Surg Center Dental Veterinary Plumbing How did you heard about Us ReferralContact Information for Individuals / Partners / Corporate OfficersName Title Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Name Title Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Hours of OperationMonday Tuesday Wednesday Thursday Friday Lunch Hours Trade References (For Account Terms & Check Payments) or Credit Card InformationCompany Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneAccount 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 Download Credit Card FormNoticeApplicant 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 CAPTCHA
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