Phone: 800-231-6444
|
|
Click on Logo to return to main page. |
|
Phone: 800-231-6444 |
mailto:sales@fwfmedicalproducts.com |
Date ____________
Name of Company:
_______________________________________________________________________________
Street Address:
_______________________________________________________________________________
City: ______________________
State/Province: __________________
Zip/Postal Code: ______________
Phone: ______(____)______________________
Fax:______(____)______________________
Our legal entity is: (check one)
Corporation
Co-Partnership
Proprietorship
If corporation list names of officers and titles. If other entity
list names of partners or owners.
Name
Address
City/State
Phone
Fax
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Annual Sales Volume:
_$_____________________________
Monthly Credit Desired:
_$_____________________________
The following are three trade references who we presently do business
with:
Name
Address
City/State
Phone
Fax Number
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Our company is Tax Exempt (check one)
Yes
No
Our Tax Exempt # is _______________
We Bank at:
__________________________________________________________________________
(Name)
(Address)
(City, State)
(Zip)