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 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