Inspiring Success Stories | Medical and Science Depot

Requested Credit Limit $:

Number of years at Business Address:

Person to contact for billing:

Please attach a copy of your tax exempt certificate

Max. file size: 50 MB.

What was your account #:

State Medical License #:

Start Date:

Expiration Date:

Date Established:

Name of Doctor Supplying Licensing Information:

Is a purchase order# required for your facility?

Name of Ownership/Corporation:

Date of Birth:

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In submitting this application, the undersigned hereby warrants the following: The information submitted is true and correct. Medical and Science Depot is authorized to investigate the applicant's credit record through any of the applicant's creditors and/or any credit reporting agency. In consideration of the extension of credit, the undersigned agrees that payment in full will be made no late than thirty (30) days from the invoice date. a 2.5% per month finance charge will be assessed on all past due balances. Applicant agrees to pay any collection costs incurred to collect the balance amount, including reasonable attorney's fees, if necessary.

Name of Principal 1:

Name of Principal 2:

Date

Signature of Principal:

Fax Credit Application to (980) 500-0039 Attn: Credit Department:

Email address of the nominee

Phone number of the nominee

Category for Nomination

Why do you believe this professional should be considered a Hero?

Practice Name(Required)

Date of the event(Required)

Link for registration

Please provide any additional details you think that might be relevant

MSD Application Rapid Form

Principal 1:

Principal 2:

TRADE REFERENCES - (Business Vendors)

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Nominee

Nominator

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