Facebook
X
LinkedIn
YouTube
Instagram
Pinterest
Permobil Blog
 

Confidential Dealer Credit Application

Submission Date

Legal Name of Company

Trade Name (if different)

Billing Information

Shipping Information

or

Additional Branch Locations (if applicable)

Location

Referral Source (How Did You Hear About Us?)

Do you have/use an ATP (Assistive Technology Professional)?

Buying Group Associations

If Applicable, member # must be provided in order for discount to be implemented.

Account Terms and Information

Account Type Requested
Sales Tax

*Please email copy of tax exemption certificate to Tamrah@ComfortCompany.com

Company Contact Information

Principal Owners/Officers

A/P Contacts

Purchasing Contacts

Person Submitting Application

Commercial Credit References

Some vendors do not provide credit references. Before submitting this application, please confirm that vendors listed on this document will provide credit references. Thank you.
The Following is a list of companies that DO NOT provide references:
*If one of the following vendors is preferred, you must call them in advance to request your credit reference.
  • Allegiance
  • Drive Medical
  • HD Smith of NJ
  • Lumex
  • ROHO
  • TAG (After Market Group)
  • Amerisource Bergen
  • DJO Global/Mobil
  • Healthline Trading
  • McKesson
  • Sammons/Patterson
  • Bruno
  • Fisher & Paykel
  • Invacare
  • Medline
  • Sunrise Medical
  • BSN Medical
  • Guardian
  • Jay Medical
  • RESMED
  • Tuffcare

Credit Reference 1

Credit Reference 2

Credit Reference 3

Bank Reference

General Provisions

This application and the information herein is a request for the extension of credit for commercial business use only and applicant certifies that the firm represented is doing business as a:
The applicant authorizes the above named creditor to obtain a written or oral credit report from any credit- reporting agency. The applicant further authorize any bank or commercial business with whom the applicant is doing or has done any type of business to give any and all necessary information to the creditor which will assist creditor in the credit investigation. The applicant further authorizes the creditor to reinvestigate the applicant’s credit status from time to time as the creditor deems necessary, and should creditor, upon such reinvestigation, deem it necessary, to limit or terminate the credit arrangement with said applicant.
Upon credit approval, Comfort Company terms are 1% 10, Net 30 days. Applicant agrees to pay any service charge assessed at the rate of 1 1/2% per month (18% per annum) for late payment of any invoice. Applicant agrees to pay for all collection and/or attorney fees, related costs and subsequent interest charges for any balance placed for collection. Applicant further agrees to the creditor’s terms of sale, a copy of which was included with this application. Should applicant, at some future time, deviate from the creditor’s terms, said creditor reserves the right to terminate future extension of credit to applicant. If applicant’s account should become delinquent or exceed the established credit limit set by creditor, orders are subject to being shipped C.O.D. or held until payment is received by creditor to bring applicant’s account to a current status.
If there is any change in the status of the applicant (name, address, principals, tax number, etc.) then notification in writing must be made to the creditor and a new credit application may have to be completed.
Certificate of Resale must be included.