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6220 Manatee Ave. W. 301
Bradenton, Fl. 34209
(941)792-7138  fax:(941)761-4613

Please Print Out This Form and Fax to: +941-761-4613

Approval takes 5 business days.
First order over $200.00 C.O.D. or
Credit Card Only...

Credit Application

Name:_______________________________
Address:______________________________
City:__________________________________
State:__________________ Zip:______-___
Phone No._____________Fax:____________
Dunn & Bradstreet #: ___________________
Federal Tax ID #: ______________________

No. of Employees  ________
Credit Amount Requested ____________
D & B Number _________________
In Business Since _______________
Organization, please check one.
Individual __ Partnership __  Non-Profit _
Corporation __ Incorporated under the laws of the state of __________________ .
Name of Parent Company _____________

Principals authorized for business transactions.

 

_________________________________________________(____)_________________
     Name/Title              Address/City/State/Zip                      Telephone Number
_________________________________________________(____)_________________
     Name/Title              Address/City/State/Zip                      Telephone Number
_________________________________________________(____)_________________
     Name/Title              Address/City/State/Zip                      Telephone Number

Bank Name _________________________
Address ____________________________
Account Number _____________________

Bank Officer _________________________
Branch ________________________
Phone Number (       ) _________________

Trade References

Firm

Contact Name

Phone Number

Account open since

1.      
2.      
3.      
I hereby certify the above information listed is accurate and correct. This information is used by 1800Endoscope.com in determining the amount and conditions of the credit to be extended. I hereby authorize the above references listed on this application to release information necessary to assist 1800Endoscope.com in providing a line of credit. All first time purchases are Fedex COD or Credit Card Purchase. 

Name/Title                                           Signature                                       Date

 

 

 

 

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1800 Endoscope.com LLC
www.1800Endoscope.com
1-800-ENDOSCOPE
ph: USA+941-792-7138 fax: 941-761-4613

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