Hopkins Medical Products
Hopkins··
Since 1945
Medical Products
6850 Southbelt Dr Caledonia, MI 49316
Toll Free 1-800-835-1995
Fax 410-484-4036
www.hopkinsmedicalproducts.com
APPLICATION FOR CREDIT
COMPAJ\>-YNAME: _____________________________
A DDRESS: _______________________________
CITY,STATE,ZIP: _____________________________
PHONE NUMBER: ___________FA XNUMBER : ______________
YEAR ESTABLISHED: _________NA\.ffi OF P ARENT CO.:-----------. P PHONEil : _______________
CONTACT FOR A.IP : __________A/
FAXFORA/P_
_
: _ _ _ _ _ _ _ _E-MAllFOR A.IP:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
FEDERAL ID NUMBER: _______.PARENT COMPA,'lfYE -MAIL : _____________
REFERENCES: (LIST ONLY THOSE \\UH WHOM YOU HAVE AN OPEN ACC01J-:-IT)
(I) NAME: __________CONTACT: _________________
A DDRE SS: _______________________________
PHONE: _( ___)__________FAX//: __(___)____________
(2)NAME: __________CONil'ACT : _________________
ADDRESS: _______________________________
PHONE: _____________FAX#: _________________
(3) NA ME: __________CONYACT : _________________
ADDRE SS: _______________________________
_FAX#:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
PHONE:_ _ _ _ _ _ _ _ _ _ _ _
_
BAl°\.'K I:\'FOIUUTION:
BAl'IKNAM E: _____________ _C ONTACT: ______________
ADDRE SS: _______________________________
PHONE _____________CHECKING ACCT#: ______________
CRE DIT APPLICATION MUST BE FILLED OUT COMPLETELY IN O RDER TO PROCESS. INCOMPLETE A PPLICATlONS
WILL BE R ETUR!'IED TO CUSTOME R Al'ID ORDER WILL REQlJlRE PREPAYMENT.
APPLICANT SIGNATURE ATTESTS FINANCIAL RESPONSIBILITY, ABILITY, A,'ID WILLINGJ\>"ESS TO PAY OUR
INVOICES ACCORDING TO OUR TERMS OF NET 30 DAYS. IF THIS ACCOUN"T IS NOT PAID AS AGREED A
DELINQlJ"ENCY CHARGE SHALL BE COMPUTE D AT THE RATE OF 1 S% PER ANNUM ON THE 1.J"NP AID BALANCE.
SIGJ\>"ED :__________________DATE: ____________
NA.�ffi: _
_ _ _ _ _ _ _ _ _ _ _ _ _ __
_ TITLE:
____________
_
Credit Application
Please complete this two page credit application. Once your organization has completed
both forms, please fax this infom1ation along with your order form to 410-484-4036.
Name of Organization:---- -------------- ------Billing Address:
Shipping Address:
)'elephone Number:
Fax Number:
Contact Person:
Does your organization require Purchase Order Numbers?
YES
NO'
Are you purchasing these items for resale?
6850 Southbelt Dr • Baltimore MD • 21208
Telephone 410 484 2036 • Fax 410 484 4036 • To order call 800 835 1995
www.hopkinsmedicalproducts.com
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