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Date:

EST Monthly Sales:*

New Account Application

Company Name:*

Billing Address:*

Ship to Address (if different from above):

City:*

State:*

Zip:*

Telephone Number:*

Fax Number:

Type of Business:*

When Business Established:

How Long at Present Location:

Owners Name:*

Home Phone:

Residential Address:

City:

State:

Zip:

 

Please List Three Business Firms With Which You Have An Open Account:

Business 1:*

Address:*

City:*

State:*

Zip:*

Telephone Number:*

Contact Person:*

Account #:

 

Business 2:*

Address:

City:

State:

Zip:

Telephone Number:

Contact Person:

Account #:

 

Business 3:*

Address:

City:

State:

Zip:

Telephone Number:

Contact Person:

Account #:

 

Bank Name:*

Address:

City:

State:

Zip:

Telephone Number:

Contact Person:

Account #:

 

Tax Exempt Status

Full Exempt:

Partially Exempt:

Non Exempt:

Dental, Medical & Industrial Gas Co.,Inc

I hereby authorize you to investigate the references listed herein or any of the other information stated to determine my qualifications for a credit account. A collection fee, representing one third (1/3) of the outstanding balance will be added if the account is referred to an attorney for collection.

In consideration of credit extended to*  I/ we hereby agree to be responsible for all the purchases made on this account. The account will be paid in accordance with our terms as stated below.

I certify all information given is correct.

Date:*

Officer's Signature:*

Terms and Conditions of Sales

Terms and Conditions of Sales


Net 30 days from the date of invoice unless otherwise shown on invoice to customers with established credit. Orders may be delayed if account is past due. Shipments to customers without established credit will be made COD until approved by our credit department. A service charge of 1 1/2 per month (18% per annum) will be added on all past due invoices.


Prices


Prices are F.O.B Readville, Ma. All prices subject to change without notice. Shipments will be invoiced at price in affect at time of shipment. Prices do not include any local or state taxes. Buyer shall be liable for all Sales, Use or Excise Taxes not included in total invoice price unless exemption certificate is on file.


Guarantee


All equipment is guaranteed to the extent of the manufacture's guarantee. No claim will be allowed for subsequent damages by consumer with delivering carrier.


Damage or Loss


All materials shipped at buyer's risk. Claims for damage or lost merchandise must be filled out by consumer with delivering carrier.


Return Policy


No credit will be given for gas cylinders or merchandise returned without corporate office authorization. The invoices number, date of delivery and the reason for the return must accompany all returned merchandise. A 25% restocking charge may be applied. Any allowed credits will be applied to future purchases. No credit will be granted for gas cylinders after 10 days of delivery.