Credit Application Form

MedEquip Depot Credit Application Form
This credit application has 6 short sections and requires the contact information of 3 people in your organization. At this time, we are only accepting credit applications from hospitals, other large medical facilities, universities, and governmental institutions.
Company Name*
DBA
New Customer?*

YesNo
Name of Applicant*

First NameLast Name
Email of Applicant*
Tel. # of Applicant*

Area CodePhone Number
EIN #*
Years in Business*
DUNS #
Facility Type
Payment Term Requested

Net 15Net 30

A/P Contact Person*

First NameLast Name
A/P Email*
A/P Phone Number*
A/P Fax Number

2nd Contact Person at Your Organization
Name*

First NameLast Name
Position
Phone Number*

Area CodePhone Number
E-mail*

3rd Contact Person at Your Organization
Name*

First NameLast Name
Position
Phone Number*

Area CodePhone Number
E-mail*

You may upload your credit reference form here (optional). However, if some data required in the section below is missing from your form, after the upload please proceed to the next section and fill out those fields.
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Fill out the section below if you haven't uploaded your own credit reference form.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Bank Information

Bank Name

Account Number

Phone Fax

Contact PersonCountry
Reference #1

Company Name

Account Number

PhoneFax

Contact PersonCountry
E-mail #1
Reference #2

Company Name

Account Number

PhoneFax

Contact PersonCountry
E-mail #2
Reference #3

Company Name

Account Number

PhoneFax

Contact PersonCountry
E-mail #3
Time Stamp

MonthDayYearHourMinutesAM/PM Option
I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended by MedEquip Depot. Upon approval of any terms or credit, our organization agrees to pay all balances as agreed. Any remaining balance will be subject to a monthly 1.5% finance charge. In the event that any balance is sent to an outside party for collections or legal action, our organization agrees to pay all collection costs, attorney fees and legal expenses incurred by MedEquip Depot. This agreement shall be governed by the laws of the state of Texas. We also agree that the venue and jurisdiction in any legal action arising from this agreement shall be exclusively set in Dallas, Texas. Furthermore, I hereby authorize the financial institutions, trade references, and any other creditors listed in this credit application to release information to MedEquip Depot and/or its agents or assignees to verify the information contained herein or in any public filings. I fully release and indemnify MedEquip Depot, its agents and representatives from any harm or damages as the result of any inaccurately reported information or bona fide error. I understand that any failure to honor this agreement will result in immediate termination of any credit extended to our organization.
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MedEquip Depot Credit Application Form

2nd Contact Person at Your Organization

3rd Contact Person at Your Organization

Fill out the section below if you haven't uploaded your own credit reference form.