Credit Application | BMP Medical

Business Contact Information

Is your order size more than $10,000?*

Yes

No

Legal Company Name*

Date Business Commenced

D/B/A

Street Address

City, State, ZIP Code

Phone*

Fax Number

Email*

Website*

Business Type*

Estimated Annual Sales

Bank Name

Expected Monthly Credit Requirement

Primary Business Address

Federal ID #

Phone

D&B # (if applicable)

Account Number

Type of Account

All invoices are to be paid within agreed upon terms.
Applicant agrees to pay a monthly service charge of 1.5%, annual rate of 18%, if charged, applied to all balances over 30 days old.
Should it become necessary to place the account with a collection agency or attorney, applicant agrees to pay all collection costs and attorney fees in addition to all other sums due.
Claims arising from invoices must be made within seven working days.
BMP Medical reserves the right to withdraw credit at any time and at its sole discretion.
By submitting this application, you authorize BMP Medical to make inquiries into the banking and business/trade references that you have supplied.

Name of the individual that filled out the application*

Date*

Purchasing Contact*

Purchasing Phone*

Purchasing Email*

Accounts Payable Contact*

Accounts Payable Phone*

Accounts Payable Email*

Method of Invoice Delivery

Email for Electronic Delivery of Invoices*

Billing Address*

Billing Street Address

Billing City, State, ZIP Code*

Preferred Shipping Method

Carrier Account Number*

Preferred Shipping Address

Shipping Street Address*

Shipping City, State, ZIP Code

Alternate Shipping Address

Alternate Street Address

Alternate City, State, ZIP Code