PATIENT ATTENTIVE CARE MEDICAL EQUIPMENT, INC.

3131 Riviera Drive, Suite 306, Sarasota, FL 34232-4739
Toll Free (877) 577-0001 ~~ Telephone (941) 379-0001 ~~ Cell (941) 321-2034
Fax (941) 923-9529 ~~ Email sales@patientmoving.com

 

DEALER AND CREDIT APPLICATION

Send per request by: ______________________


COMPANY INFORMATION ORGANIZATION

Legal Name: ______________________________________________________

 

 Partnership

Operating As: _____________________________________________________

 

 Proprietorship
Subsidiaries/Division: _______________________________________________ Corporation

Principals & Position: ______________________________ Date Established: _______________

Federal ID#: __________________ State Seller’s Permit #: _________________ (attach copy)

General Liability Insurance: ____________________________ (Attach copy of page 1 of policy)

Any other license (e.g. contractor’s license): __________________________________________

Estimate amount of monthly credit required: $_______________________
Billing Address: ___________________________________________________________________
City: _______________________________ State: ________________ Zip: _________________
Telephone: __________________________ Fax: _______________________________________
A/P Contact: ________________________ Purchasing Contact: __________________________
Shipping Address: _________________________________________________________________
City: _______________________________ State: ________________ Zip: __________________

BANKING INFORMATION

Bank Name: ______________________________________________________________________
Address: _________________________________________________________________________
City: _______________________________ State: ________________ Zip: __________________
Telephone: ______________________________ Fax: ____________________________________
Account #: __________________________ Purchasing Contact: __________________________

TRADE REFERENCES

1) Company:______________________________________________________________________
City: _____________________________ State: __________________ Zip: __________________
Telephone: _______________________________ Fax: ___________________________________
Contact Name/Position: ____________________________ Account #: ______________________

2) Company:______________________________________________________________________
City: _____________________________ State: __________________ Zip: __________________
Telephone: _______________________________ Fax: ___________________________________
Contact Name/Position: ____________________________ Account #: ______________________

3) Company:______________________________________________________________________
City: _____________________________ State: __________________ Zip: __________________
Telephone: _______________________________ Fax: ___________________________________
Contact Name/Position: ____________________________ Account #: ______________________

LIST OF ALL AUTHORIZED PURCHASERS

Name: ______________________________________ Title: _______________________________

Name: ______________________________________ Title: _______________________________

Name: ______________________________________ Title: _______________________________

Name: ______________________________________ Title: _______________________________

 

PAYMENT TERMS

Initial order and until credit is approved: C.O.D / Cash in Advance (Company check or Company credit card)

After Credit Approval: Net 30 days from the date of invoice


This information is submitted by the undersigned for the purpose of obtaining credit. The information is to be kept in confidence and used only for the purpose of credit evaluation. I hereby authorize PACMed to obtain information concerning our credit from the above references. I, the undersigned, have read and agree to comply with the policies and payment terms as outlined in the Dealer Application, Price List, and Order Confirmation.


_______________________________________ ________________________________________
SIGNATURE (PLEASE PRINT – Must be a signing Officer)                                       SIGNATURE


_______________________________________ ________________________________________
POSITION DATE

_______________________________________ ________________________________________
SIGNATURE (PLEASE PRINT – Must be a signing Officer)                                       SIGNATURE


_______________________________________ ________________________________________
POSITION DATE


DEALER AREA INFORMATION

Office Only: Yes No

Show Room: Yes No If yes, Size: ________________________________________

Number of employees: _______________

Area/State where business in conducted: ____________________________________________

Other Offices: ___________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________


Please attach proof of insurance for comprehensive general liability.