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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________________________________________________________

 

NAME______________________________________________

ADDRESS_________________________ CITY______________ STATE_____ZIP______

ACCOUNT #__________________  TELEPHONE#________________________

TYPE OF BUSINESS________________________________________________________

 

NAME______________________________________________

ADDRESS_________________________ CITY_____________ STATE_____ZIP_______

ACCOUNT #__________________  TELEPHONE#________________________

TYPE OF BUSINESS________________________________________________________

 

NAME_____________________________________________

ADDRESS_________________________ CITY______________ STATE_____ZIP______

ACCOUNT #__________________  TELEPHONE#________________________

TYPE OF BUSINESS________________________________________________________

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_____________________