Credit Application

Contact Information

First Name

Last Name

Address Line 1

Address Line 2

City

Zip Code

Phone Number

Business and Credit Information

Number of Employees

UBI Number

Amount of Credit Requested

Date Business Established

Have You had Credit with us Before?

Yes

Are You Tax Exempt?

Must be state recognized tax exempt certificate.

Chief Corporate Officers or Partners

First Name

Last Name

Address Line 1

Address Line 2

City

Zip Code

Phone Number

Title

Accounts Payable Contact Information

First Name

Last Name

Phone Number

Ext.

Email Address

Fax

Business / Trade References

*Business Name

Address Line 1

Address Line 2

City

Zip Code

Phone Number

Bank References

*Bank Name

Address Line 1

Address Line 2

City

Zip Code

Phone Number

Signatures

I represent that the above information is true and is given to induce QuickMedical to extend credit to the applicant. My company and I authorize QuickMedical to make such credit investigation as QuickMedical sees fit, including contacting the above trade references and banks and obtaining credit reports. My company and I authorize all trade references, banks, and credit reporting agencies to disclose to QuickMedical any and all information concerning the financial and credit history of my company and myself.

*Name

Title

*Date

I have read the terms and conditions stated above and agree to all of these terms and conditions.

Business Credit Application

Company Information

Contact Information

Business and Credit Information

Chief Corporate Officers or Partners

Accounts Payable Contact Information

Business / Trade References

Bank References

Signatures