Credit Application Form printable pdf download

7910 S. 3500 E. Suite C

Salt Lake City, UT 84121

Phone: 800-397-5899 Fax: 801-733-5797

CREDIT APPLICATION

(Please print clearly)

Company Name________________________________ Year Established___________ Contact Name_____________________________

Tax ID# _____-_______________ Owner Social Security #_______-______-__________ Dun & Bradstreet #______________________

Billing Address___________________________________________ City_______________________ State________ Zip______________

Shipping Address__________________________________________ City_______________________ State________ Zip_____________

Phone #(_______)___________________Fax #(_______)_________________Email___________________________________________

A/P Contact________________________ Phone #(______)________________Email___________________________________________

Preferred method for receiving invoices:  E-mail to: ____________________________________________________________________

(Please check one)

 Fax to: (______)_______________  Mail to billing address above

Credit Limit Requested: $______________

LEGAL BUSINESS STATUS:

 CORPORATION

 PROPRIETORSHIP

 PARTNERSHIP

 OTHER

Has your company ever filed for bankruptcy protection? ______

Are you currently considering it? ______

BANK REFERENCE

TRADE REFERENCES:

*You must include either a fax number or e-mail address for each contact, including your bank reference. Failure to provide this may

result in a delay in setting up an account with us. Please include an account number for each reference, if available.

Bank Name________________________________________

Company Name_____________________________________

Contact Name______________________________________

Address___________________________________________

City____________________State________Zip____________

Phone #(_________)________________________________

Fax #(__________)_________________________________

Account #_________________________________________

Email _____________________________________________

Company Name_____________________________________

Contact Name______________________________________

Address___________________________________________

City____________________State________Zip____________

Phone #(_________)________________________________

Fax #(__________)_________________________________

Account #_________________________________________

Email _____________________________________________

AUTHORIZATION FOR RELEASE OF CREDIT INFORMATION:

I AUTHORIZE THE BANK AND TRADE REFERENCES LISTED ABOVE TO RELEASE CREDIT INFORMATION ABOUT MY COMPANY. ALL INFORMATION

OBTAINED BY VITALITY MEDICAL, INC. FROM THESE REFERENCES WILL BE KEPT CONFIDENTIAL.

I HEREBY APPLY FOR A CREDIT ACCOUNT WITH VITALITY MEDICAL, INC. I AM AUTHORIZED BY MY COMPANY TO REQUEST SUCH AN ACCOUNT. I

UNDERSTAND THAT MY COMPANY WILL BE RESPONSIBLE FOR ANY AND ALL LEGAL FEES INCURRED BY VITALITY MEDICAL, INC. FOR THE

COLLECTION OF ANY DELINQUENT INVOICES OF MY COMPANY. I FURTHER UNDERSTAND THE TERMS OF SALE ARE NET 30 DAYS FROM THE DATE

OF INVOICE AND THAT DELINQUENT INVOICES OVER 45 DAYS WILL BE CHARGED A $45 LATE FEE AND A FINANCE CHARGE OF 1.5% PER MONTH

(18% ANNUALLY) AND AT THE DISCRETION OF VITALITY MEDICAL, INC., OUR COMPANY MAY BE PLACED ON A PREPAY STATUS OR CREDIT HOLD

FOR DELINQUENT PAYMENT.

SIGNED X:________________________________ TITLE:______________________________ DATE:___________________

PERSONAL GUARANTEE

FOR GOOD AND VALUABLE CONSIDERATION, THE UNDERSIGNED AGREES TO BE PERSONALLY LIABLE FOR ALL INDEBTEDNESS INCURRED BY THE

ABOVE LISTED CORPORATION OR BUSINESS ENTITY. THE UNDERSIGNED FURTHER AGREES TO BE PERSONALLY LIABLE FOR ALL INDEBTEDNESS

BASED ON THE EXTENSION OF CREDIT TO ANY OTHER CORPORATION OR BUSINESS ENTITY WITH WHICH THE UNDERSIGNED IS OR MAY BE

AFFILIATED.

SIGNED X:____________________ SOCIAL SECURITY #:____-____-______TITLE:______________________DATE:________

Please complete this form, sign it*, and return via Fax to: (801) 733-5797

*Both signatures are required in order to process your application.

Credit Application Form

Related Articles

Related forms

Related Categories