The Aspirator & Compressor Company
MEDICAL SPECIFICS, INC.
3306 WILEY POST ROAD SUITE 106/ CARROLLTON, TEXAS 75006
TELEPHONE: (972) 980-6871 (972) 980-6873 FAX
DEALERSHIP NET 30 DAY CREDIT APPLICATION AND AGREEMENT
This information MUST be completed, so credit can be processed.
COMPANY NAME ____________________________________________________________
A.K.A. OR DBA (If different from above) _________________________________
STREET ADDRESS __________________________________________________________
CITY _____________________ COUNTY_______________ STATE_____ ZIP__________
PHONE: ( ) _______________ FAX ( ) _____________________
WEBSITE _________________________ EMAIL ______________________
( ) PROPRIETORSHIP ( ) PARTNERSHIP ( ) CORPORATION
BUSINESS STARTED_________ DATE INCORPORATED__________
SALES TAX EXEMPT #__________________________________
TYPE OF BUSINESS __________________ EQUIPMENT SOLD _____________________
LIST ALL PRINCIPALS, PARTNERS, CORPORATE OFFICERS
NAME__________________TITLE_______ NAME___________________TITLE _______
RESIDENCE_________________________ RESIDENCE___________________________
CITY______________STATE___ZIP_____ CITY_______________STATE___ZIP______
HOME PHONE #______________________ HOME PHONE #________________________
SS#_______________________________ SS#_________________________________
NAME__________________TITLE_______ ALL INFORMATION WILL BE HELD IN
RESIDENCE_________________________ STRICTEST CONFIDENCE.
CITY______________STATE___ZIP_____
HOME PHONE#_______________________
SS#_______________________________
BANK REFERENCES
NAME OF BANK________________________ ACCOUNT #__________________________
ADDRESS_____________________________ Checking____Savings_____Other_____
CITY_______________STATE___ZIP______
PHONE NUMBER: ( )_______________
What is the Name the account is listed under:___________________________
TRADE REFERENCES
COMPLETE NAMES & ADDRESSES FOR US COMPANIES WITH ACCOUNT #
FOUR (4) REFERENCES NEEDED (Competition will not reply)
NAME______________________________________________
ADDRESS_________________________ CITY_____________ STATE_____ZIP_____
ACCOUNT #___________________ TELEPHONE#________________________
TYPE OF BUSINESS________________________________________________________
ADDRESS_________________________ CITY______________ STATE_____ZIP______
ACCOUNT #__________________ TELEPHONE#________________________
ADDRESS_________________________ CITY_____________ STATE_____ZIP_______
NAME_____________________________________________
OPEN ACCOUNT INVOICES ARE DUE 30 DAYS FROM INVOICE DATE.
WE RESERVE THE RIGHT TO CHANGE NET 30 DAYS TO CASH IF THE ACCOUNT
GOES PAST DUE.
In the event my/our company defaults in payment of bills and is turned over for collection, I/we shall be totally liable for any fees and sums charged by the collection agency or attorney. If any suit or other judicial proceeding is instituted or has thereon, or is collected through probate or bankruptcy proceeding, my/our company will be totally liable for all attorney's fees and court costs incurred by Medical Specifics, Inc. in the collection of said bills.
Date___________________ Applicant_______________________________________
By______________________________________________
Title___________________________________________
Date submitted_______________________ Date Approved_____________________