Avella Wholesale, Inc.

Transcription

1 Credit Application Form Applicant Information Applicant Name: Address: Company Information Company Name: DBA Name (If Applicable): Company Address: Tax ID (FEINISSN): Billing Contact: Banking Information Fax: Bank Name: Bank Address: Account Number: Bank Contact Name: Guarantor Information Bank Contact Guarantor Name: Guarantor Address: SSN: Date of Birth:

2 Credit Terms and Conditions Credit Terms & Conditions The undersigned (the Customer ) hereby agrees that all purchases shall be subject to terms and conditions as follows: 1. Credit Approval is at the discretion of the AR Manager and is not guaranteed. 2. Upon Avella Wholesale, Inc. (hereafter referred to as Avella) approval of a signed Credit Application, Applicant may order products from Avella as a Customer on open account terms. For purposes of the terms and conditions, a Customer shall mean any person who purchases products from Avella, the Applicant, the Personal Guarantor, and any other person that Applicant notifies Avella may purchase products from Avella that will be paid for by the Applicant. 3. The Customer hereby authorizes Avella permission to run a credit check through Experian on the above named business prior to granting that applicant credit on account. 4. The Customer understands that if the above named business is not found in the credit reporting database or credit history is insufficient to make a decision regarding credit limit, additional financial information will need to be provided before credit is granted. 5. The Customer hereby authorizes the financial or banking institution identified in the credit application to release to Avella credit information relating to the accounts listed. 6. Avella credit terms are determined by the AR Manager and are assigned after credit review. Payment is due from the date of product shipment. Should the Customer elect to pay from the Avella monthly customer statement, it is the Customer s responsibility to insure that the payment is received at the above address. 7. The Customer may elect to setup automatic payment options with Avella. If this option is requested the Customer must also fill out an ACH or Credit Card Authorization form. 8. A monthly fee of 1.5% (18% APR) will be assessed each month for unpaid balances exceeding terms. From time to time, as determined in the sole discretion of Avella, in connection with the sale of goods and equipment to the Customer, Avella retains and reserves the right to amend these terms and conditions with or without notice to the Customer. 9. Checks in payment for goods that are not honored by the bank upon which drawn shall be subject to a minimum of $25.00 service charge payable to Avella. Additionally, Avella will require wire transfers or certified checks for all future payments. 10. The Customer shall promptly notify Avella, by certified mail, any change in ownership and/or billing information of the Customer, or if the Customer files bankruptcy. Bankruptcy will result in the account being permanently closed. 11. If the Customer s account becomes past due, and Avella, a collection agency and/or attorney seeks to collect such past due amounts, then in addition to the amount past due, the Customer shall pay to Avella all collection costs, attorney s fees, court costs, and any other costs or fees incurred by Avella in order to recover past due amounts owed by the Customer, together with interest at the maximum rate allowed by law. Customer will be sent to Collections without prior notice if payment is not received within 30 days from date of invoice. 12. The extension by Avella of credit to the Customer and the amount, terms and conditions of such credit will be in sole absolute and exclusive discretion of Avella. Avella reserves the right to terminate the extension of credit to the Customer at any time with or without notice and to change any of the credit terms upon notice to the Customer. Customer acknowledges that Avella will rely upon the representations made in the credit application for the purpose of extending credit to the Customer. 13. No returns on any medications unless the following occurs: (1) Manufacturer Defect, (2) Shipping error by Avella, or (3) Products are damaged in transit.

3 Credit Approval Form Company Information Company Name: Company Address: Business Owner Information Business Owner Name: Current Address: Credit Agreement Please check all that apply and sign that you have read and accept terms of this agreement I have read and agree to the above credit terms I hereby authorize my banking institution to release to Avella credit information relating to the accounts listed. I hereby authorize Avella to run a business credit check If additional financial information is required Please elect one of the following: I hereby authorize Avella to run a Business Owner Profile Report I do not authorize Avella to run a Business Owner Profile Report, but will provide audited financial statements upon request. Account Holder Name: (please print) Account Holder Signature: Date:

4 Wholesale Account Setup Form Business Information: Business Name: Business Address: Business Order Information: Business Doctor s Name: Doctors DEA #: Doctors Medical License #: Individuals Authorized to Place Orders: Delivery Address: Order Contact: Contact Account Billing Information: Contact Contact Fax: Billing Address: Billing Contact: Contact Contact Contact Fax: Please attach a copy of the doctors DEA and Medical License

5 Applicant Information Credit Card on File Authorization Form Patient Name: Patient ID Number: Current Address: Social Security Number: Caregiver Name: Date of Birth: Telephone Number: Credit Card Information Card Holders Name as it appears on Card: Card Holders Address: Card Holders Telephone: Credit Card Number: Expiration Date: Cardholder Agreement CCV Number: I, the card holder, hereby authorize Avella Specialty Pharmacy to charge the above mentioned credit card for unpaid balances on my account without signature. I understand that monthly deductions will be made per agreed upon payment schedule until the balance is paid in full. I acknowledge that any changes to the above account must be communicated to the AR Department prior to the 10 th of each month. Additionally, I authorize the above information will be held on file by Avella Specialty Pharmacy. Printed Name of Cardholder: Signature of Cardholder: Date of Authorization:

6 Applicant Information ACH Deduction Authorization Form Patient Name: Patient ID Number: Current Address: Social Security Number: Caregiver Name: Date of Birth: Telephone Number: Banking Information Account Holders Name: Account Holders Bank Name: Bank Address: Routing Number: Account Holder Agreement Account Number: I, the account holder, hereby authorize Avella Specialty Pharmacy to charge the above mentioned account for unpaid balances on my account without signature. I understand that monthly deductions will be made per agreed upon payment schedule until the balance is paid in full. I acknowledge that any changes to the above account must be communicated to the AR Department prior to the 10 th of each month. Additionally, I authorize the above information will be held on file by Avella Specialty Pharmacy. Printed Name of Account Holder: Signature of Account Holder: Date of Authorization: Please attach a voided check or letter from your bank to verify account information