Customer Information Form Us Orthotics printable pdf download

Customer Information Form

8605 Palm River Rd - Tampa. FL 33619 - 800-825-5228 -

- Fax – 813-623-1055

COMPANY

Business Name ____________________________________________ Phone ______________________

Street Address ______________________________________________ Fax ______________________

City ___________________________ State _____________ Zip ________________

Web Address _____________________________ email address_________________________________

Year Established ____________ Federal ID Number _______________________

OWNERSHIP Type of Business Corporation _______ Partnership ______ Individual ______

President __________________________________ Vice President ______________________________

Treasurer _____________________________ Accounts Payable Manager _________________________

FINANCE

Bank Name _____________________________Bank Address __________________________________

City ______________________ State __________ Zip ___________ Phone _________________

Credit Amount Requested $______________________

TRADE REFERENCES Name Address City State Zip Phone Fax

1) ________________________________________________________________Fax________________

__________________________________________________________________________________

2)________________________________________________________________Fax________________

__________________________________________________________________________________

3)________________________________________________________________Fax________________

________________________________________________________________________________

IMPORTANT:

Our terms are net 30 days from invoice date. Any invoice past 60 days will result in a credit hold being placed on the

account. A 1 ½% monthly service charge will be added on delinquent accounts starting from the date of invoice. I certify that the above

information is true and correct and that I fully understand the credit terms and agree to proper payment in consideration of extended credit.

All returns must be in original sealed packaging, have an authorization number and are subject to a minimum 20% restocking charge. Special

orders are not returnable. If the business is a corporation, partnership or limited partnership the undersigned agrees to be personally

responsible for any obligations of the company listed above. I authorize information pertaining to our credit and financial position to be

released to U.S. Orthotics, Inc.

All financial information will be held in the strictest of confidence.

Date _________________

Signed ____________________________________________Title _______________

Customer Information Form Us Orthotics