Credit Application Form

Medisol Pharmaceuticals - Credit Application

ACH DraftCheck

YesNo

No Statement (Pay by Invoice)EmailFaxI will Obtain Statement Online

Sole proprietorPartnershipCorporationLLC


Trade Reference : Please list primary wholesaler on line one

Name
Address/city/state/zip
Account#
Telephone

I, undersigned, guarantee all payments of existing and future obligations and unconditionally waive the right to any amount paid pursuant to this provision. The undersigned also agrees to jurisdiction and venue in Dallas, Texas. The above statements are made for the purpose of procuring credit from Medisol Pharmaceuticals LLC. The undersigned hereby consents to the confirmation by company, of the information contained herein and authorizes company to contact the undersigned’s bank and all credit references and obtain any necessary credit reports.

Terms of sale have been fully explained and I understand that if an account is established, my credit line is subject to periodic review. Also shipments may be held if my account is delinquent or exceeds my established line of credit. The undersigned further represents that its professional licenses are in good standing and not the subject of any proceedings by any government agency and agrees to notify the seller immediately upon the commencement of any such proceedings. The undersigned authorizes company to take appropriate measures in verifying the credit of the undersigned and releases company from any obligation while researching this information. Customer and guarantor agree to provide company with 60 days’ notice of its intention to sell all of its assets. Special contract pricing is subject to verification of entitlement at any time after the sale and customer agrees to refund in the event there is no entitlement.

Please include a copy of your state board and DEA license and sales tax exempt (if applicable)
The Medisol Pharmaceuticals, Its division and affiliates, May from time to time, provide promotional information via phone, fax or email to its customers. You may request to be removed from any of their channels by contacting Medisol by email, fax, or phone. The federal equal credit opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status; age;(provide the applicant has the capacity to enter into a binding contact); because all or part of the applicant’s income derives from any public assistance program; or because the applicant has in good faith exercise any right under the consumer credit protection act.