Credit Application

STAT Credit Application:

Company Name:*
Number of Years in Business:
Billing Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is shipping address the same as billing address?*
- Yes
- No
Shipping Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Type of Organization?*
Name of the Subsidiary:*
Phone:*
Fax:
Email:
Enter Email Confirm Email
Website:
Corporate Contact Information:
Purchasing Agent Name:
First Last
Purchasing Agent Phone:
Purchasing Agent Email:
Enter Email Confirm Email
Accounts Payable Contact:
First Last
Accounts Payable Contact Phone:
Accounts Payable Contact Email:
Enter Email Confirm Email
Controller/CFO Name:
First Last
Controller/CFO Phone:
Controller/CFO Email:
Enter Email Confirm Email
Trade References:
Company 1 Name:*
Company 1 Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Company 1 Phone:*
Company 2 Name:*
Company 2 Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Company 2 Phone:*
Company 3 Name:*
Company 3 Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Company 3 Phone:*
Bank Relationship:
Bank Name:*
Bank Phone:*
Bank Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Bank Account Number*
Credit Line Requirement:
Estimated Monthly Purchases:*
Name of Individual Completing Application:*
First Last
Title:*
By clicking "submit" the applicant agrees that the provided information is accurate and true. In order to induce Stat Medical Devices, Inc. to establish a line of credit based on this application, the applicant agrees to pay for all purchases in accordance with Stat Medical Devices, Inc. terms of sale. In the event it becomes necessary for Stat Medical Devices, Inc. to incur costs for collection agencies or attorney fees in order to collect this debt, applicant agrees to reimburse Stat Medical Devices, Inc. for all costs. Applicant further agrees to pay any late charges assessed for past due invoices and authorizes Stat Medical Devices, Inc. to verify credit information provided above by contacting the references listed.

STAT Credit Application:

Corporate Contact Information:

Trade References:

Bank Relationship: