Delco Innovations- Credit Application
Company Profile
Legal Company Name
Primary Phone
Shipping Address
Billing Address (if different than shipping)
Business Information
Type of Business
Enter Type of Business
Chiropractic
Distributer
DME Company
Drop-Ship Company
Family Medicine
Hand Specialist
Neurology
Neurosurgery
O&P
Orthopedic
Pain Medicine
Physical Medicine
Podiatry
State of Incorporation
Year Business was Created
Tax Exempt?
Yes
No
Tax Exempt Number
Are you a member of a purchasing group?
Yes
No
Officers, Partners, or Owner of Business
Name (First & Last); Title; % Ownership
Name (First & Last); Title; % Ownership
Name (First & Last); Title; % Ownership
Accounts Payable Contact
Payment Preference Type
Select an option
ACH
CC
Mail Check
Wire
Accounts Payable Contact (First & Last Name)
Accounts Payable Phone
Accounts Payable Email
Payment Information
Please complete the section below if you would like to keep a credit card on file to be processed per Net30 terms
Credit Card Type
Enter Credit Card Type
American Express
Discover
Master Card
Visa
Credit Card Number
Name on Credit Card
Expiration Date
CVC (3- or 4- Digit Security Code)
4
Credit Card Billing Zip Code
Authorization Consent
I certify that I am an authorized user of this credit card/bank account and will not dispute the transactions with my bank or credit card company, provided the transactions correspond to our contractually established payment terms and orders placed.
I agree to the terms & conditions stated above
Card Holder Signature
Clear
Card Holder Name
Reference- Financial
Name of Bank
Account Number
Phone Number
Business Address
Guaranty
To induce Delco Innovations, LLC. & Trend Medical, LLC. to sell goods to the applicant, the undersigned agrees to the above terms, which are herein incorporated and personally guarantees and agrees to pay, when due. Upon demand, the total amount of any indebtedness, including attorney fees and costs incurred for collections, owed to Delco by the applicant in connection with such sales.
I agree to the terms & conditions stated above
Guarantors Signature
Clear
Guarantors Name
Submit