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Email:  sales@fwfmedicalproducts.com

Please print this page,  fill in the form below,  then fax,  800-452-5534,  or mail it to us.

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)                       


Authorization to Release Information
I hereby authorize our bank to release any information necessary to assist in establishing a line of credit with Falls Welding & Fabricating, Inc.