Twinmed - Credit Application

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Customer Information and Credit Sheet

General Information
Company Name:
Contact Person :
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Type of Business :
Number of Employees:
Date Business Established :
Amount of Credit Requested :
Business Setup

Are you a:

Corporation

State of Incorporation:

Federal Tax ID#:

Names, titles, and addresses of your three chief corporate officers:

Name	Title	Address

Name and address of your resident agent:

Name	Address

Partnership

Names, addresses, and Social Security numbers of your partners:

Name	Address	SS#

Sole Proprietorship

Names, addresses, and Social Security numbers of the owners:

Name	Address	SS#

Additional Information
Are you sales tax exempt?	yes no resale #
Have you ever had credit with us before?	yes no
If yes, under what name?
Purchase order required?	yes no
References

Trade References

Company Name:
Address:
Phone:
Fax:
Email:

Company Name:
Address:
Phone:
Fax:
Email:

Company Name:
Address:
Phone:
Fax:
Email:

Bank References

Bank Name:
Contact Person:
Address:
Phone:
Account Type:
Account #:

Bank Name:
Contact Person:
Address:
Phone:
Account Type:
Account #:

I represent that the above information is true and is given to induce TwinMed, LLC to extend credit to the applicant. My company and I authorize TwinMed, LLC to make such credit investigation as it sees fit, including contacting the above trade references and backs and obtaining credit reports. My company and I authorize all trade references, banks and credit reporting agencies to disclose to TwinMed, LLC any and all information concerning the financial and credit history of my company and myself.

I understand and agree that any disputes or conflicts between myself (and/or my business and/or my corporation) and TwinMed, LLC arising out of or relating to any transaction between the aforementioned parties shall be adjudicated under California law. Furthermore, any and all disputes or conflicts between myself (and/or my business and/or my corporation) and TwinMed, LLC shall be adjudicated in the appropriate California Superior Court, to whose jurisdiction I hereby submit to, unless all parties stipulate otherwise in writing.

GENERAL TERMS AND CONDITIONS AND PERSONAL GUARANTEE

Statements are sent on the tenth day of each month.
All bills become payable in full according to terms and if not paid according to terms are considered past due.
A service charge of 1.5% per month will be added to all amounts billed if not paid according to terms.
No additional credit will be extended to past due accounts unless satisfactory arrangements are made with our credit department.
PERSONAL GUARANTEE: If the credit customer is a corporation, then those signing this application, whether signing as an officer or not, personally guarantee payment for all items purchased on credit by the corporation.

By clicking on "Submit," you affirm that the information you have provided
is correct and agree to TwinMed's terms and conditions.