Credit Account Application
Date:__________________
Please fill out and SIGN this
application and Fax to 910-323-3106 OR
Mail to Carolina Physician Records & Systems, 846-E Elm St.,
Fayetteville, NC 28303
BUSINESS TYPE:
___ SOLE PROPRIETORSHIP ___ PARTNERSHIP ___ CORPORATION - IN STATE OF ______
NUMBER OF YEARS IN BUSINESS: _____ D & B NUMBER:_____________
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COMPANY NAME:
__________________________________________________
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NAME AND ADDRESS OF INDIVIDUALS OR PARTNERS -
NAME, TITLE, PHONE NUMBER OF CORPORATE OFFICERS: _________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
NAME OF PERSON TO CONTACT REGARDING PURCHASE ORDERS AND INVOICE PAYMENTS
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TITLE, ADDRESS, AND PHONE NUMBER: _________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
BANK REFERENCE -
BANK ACCOUNT NUMBER, CONTACT, TITLE, AND PHONE NUMBER:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
TRADE REFERENCES -
COMPANY NAME, ADDRESS, CONTACT AND TITLE, AND PHONE NUMBER:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
THE ABOVE INFORMATION IS HEREWITH SUBMITTED
FOR THE PURPOSE OF OPENING AN
ACCOUNT AND I DO
HEREBY CERTIFY THIS INFORMATION TO BE TRUE.
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SIGNED:
________________________________________ |
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