CuraMedica,  LLC

APPLICATION FOR CREDIT

 

 

PRINT COPY AND FAX TO  (336)626-7732         ATTN:  CREDIT DEPT.

 

 

Date ____________       Taxable: yes________ no________ (Attach copy of tax certificate if applicable)

Exact Legal Name of Applicant __________________________________________________________________

Street Address ___________________________________ P.O.Box ________________ Phone (___) __________

City ______________________________________________ State _________________ Zip Code __________

Complete Appropriate Spaces:

Corporation ________ Partnership _________ Proprietorship _________ Limited Liability Co. _________

# Years in business ________

# of Employees ___________

Geographic areas served _____________________________________________________________________________

Is your company a subsidiary or division of another company? _____________  If yes, name and address of parent company

_________________________________________________________________________________________________

Name of President, Owner or Partners (List legal names and provide the information requested)

              Officer/Owner, Name/Title

1.        ___________________________________________________________________________________________

2.        ___________________________________________________________________________________________

3.        ____________________________________________________________________________________________

Are Purchase orders required? yes ________ no________
 
Person to contact regarding Accounts Payable: _______________________ Phone # _________________

Bank References: Bank Name, Contact, Address, Phone Number

1. ____________________________________________________________________________________

2. ____________________________________________________________________________________

 

Trade References: Name, Contact, Address, Phone Number

1. ____________________________________________________________________________________

2. ____________________________________________________________________________________
 
3. ____________________________________________________________________________________ 

 

 

Can you anticipate your annual volume with us? $ __________________
What are your estimated annual sales for this year? $ _________________
Have you ever filed for bankruptcy? yes________ no_________

 

 

Billing Terms:

Curamedica agrees to extend the following terms: 2% 15 days, net 30.

$500.00 minimum order

Signature authorizes release of credit information from references listed. 

 

Name:__________________________________________________________

 

Title:___________________________________________________________