Credit Application
In order for us to open a new account, please print,then fill out and fax this form to
(305) 777-8871.
| Name: | __________________________________________ |
| Bill To Address: | __________________________________________ |
| __________________________________________ | |
| Ship To Address: | __________________________________________ |
| __________________________________________ | |
| Phone: | __________________________________________ |
| Fax: | __________________________________________ |
| Pres./Owner/Partner: | __________________________________________ |
| Type of Business: | __________________________________________ |
| Products of Interest: | __________________________________________ |
| Purchasing Agent: | __________________________________________ |
| Bank Name: | __________________________________________ |
| Account Number: | __________________________________________ |
| Bank Phone: | __________________________________________ |
| Bank Contact: | __________________________________________ |
| Trade Reference: | __________________________________________ |
| Trade Ref. Phone: | __________________________________________ |
The bank and trade references listed above are hereby authorized and requested by the undersigned to release financial and credit information concerning our accounts.
| Applicant: | ______________________________________________ |
| Date: | ______________________________________________ |
| Signature By: | ______________________________________________ |
| Title: | ______________________________________________ |
You must provide a current copy of these documents with this application:
State License
and or
D.E.A. Certificate
Miami, FL 33166 USA
Phone: (305) 477-5352
Fax: (305) 777-8871
E-mail: salesfl@flomedcorp.com
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Last modified: Fri Aug 14 2009