Fax: (905) Phone:

Transcription

1 Please fax or your completed account application to: DRIVE MEDICAL CANADA Fax: (905) Phone: * Be Sure to Include Your Sales Representatives Name (if known) on the Application *

2 Drive Medical Canada 256 Aviva Park Drive, Unit 2 Vaughan, Ontario, L4L 9C7 account application Toll Free: Fax: canadacustomerservice@drivemedical.com Change of Ownership o New Customer o For Account # Changes to Existing Account # Date: Exact Legal Name of Business: DBA ( if different) Reason for Change: DUN & BRADSTREET (DUNS): (Needed to establish credit line) City: Province: Postal Code: Country: Phone #: Fax #: Website: AP Contact: AP Phone #: AP # Employees: Date Established: Requested Payment Terms: APPLICANT S OFFICERS, PARTNERS, OR OWNER (LIST ALL WITH 10% OR MORE OWNERSHIP): (NAME) (TITLE) (PHYSICAL HOME ADDRESS) (SOCIAL SECURITY #) (% OF OWNERSHIP) * Have Owners or Principals ever Filed Bankruptcy (If yes, explain details) o NO o YES DRIVE MEDICAL GOES GREEN - Please provide an address for the following: I want my monthly statements ed to: I want my invoices ed to: Legal Form: o LLC o Not for profit Corporation o General Partnership o Limited Partnership o Sole Proprietorship o Wholly Owned Subsidiary o Partially Owned Subsidiary o Corporate Charter, Province, or Partnership/Proprietorship Registration Locale: TAX RESALE CERTIFICATION o Tax Exempt - exempt from Drive charging you sales tax, eg. First Nation and Aboriginal o No resale certificate-i agree to pay applicable sales tax Intitial Drive Credit Application Page 1 of 4

3 BANK REFERENCES Bank Name: City/State/Zip Code: Bank Officer: Phone: Fax: o checking acct. #: savings acct. #: o revolving line o term loan(s) o mortgage o other Do you have any loans presently outstanding? YES o NO o If yes, itemize below: Lender Name Address Phone Contact Present Balance Term of Loan TRADE REFERENCES (PLEASE DO NOT INCLUDE INVACARE, SUNRISE, PRIDE, MEDLINE OR AMG MEDICAL) Company Name Address Phone # Fax# Account # ADDITIONAL CUSTOMER INFORMATION SO WE CAN SERVE YOU BETTER PLEASE DESCRIBE MAIN ACTIVITIES AND AFFILIATES (ALSO ATTACH A BUSINESS PLAN IF AVAILABLE) PLEASE CHECK THE BOX THAT CORRESPONDS TO THE SPECIALTY OF YOUR BUSINESS: Type of business: o HME Provider / Dealer o National Wholesale Distributor o International Wholesale Distributor o Ecommerce o National Retailer o Other (Speficy) Please break down your revenue percentage: DME REHAB RESPIRATORY OTHER ESTIMATED MONTHLY SALES: $ PLEASE CHECK PREFERRED METHOD OF ORDER ENTRY (Check all that apply) o EDI o Fax o Phone o o Web PURCHASING INFORMATION: (First) (Last) Name: Title: Tel #: Receiving Agent: Purchasing Agent: Other: Office Manager: Would you like to receive s about special promotions, new products and offers? o Yes o No Would you like more information regarding our equipment financing program? o Yes o No (Enter address) Drive Medical respects your privacy. Please see our Privacy Policy at Drive Credit Application Page 2 of 4

4 SHIPPING REQUIREMENTS: Does your location require Lift Gate ($35 additional charge) * Yes No Does your location require Inside Delivery ($50 additional charge) * Yes No Does your location require an Appointment * Yes No Is your location a House of Worship, Hospital, Self Storage Facility, Nursing Home, Military Base or other location considered to be Limited Access ($50 additional charge) * Yes No Can your location accommodate a 53 tractor trailer (for freight deliveries only)? * Yes No *May add additional transit time (typically 1 day) Would you require Drive Medical Design & Mfg. to ship your orders billed via Third Party or Collect? Yes No If yes, please attach directions inclusive of Carrier name and account numbers. Small Package Carrier: (up to 150 lbs.) Acct:# Type: Third Party or Collect (please circle) Freight Carrier: Acct:# Type: Third Party or Collect (please circle) Does your location have special receiving hours? if so from to Do you have any other special shipping requirements, if yes, please describe: (Third party only) (Third party only) PLEASE PROVIDE ALL SHIP TO ADDRESSES ON A SEPARATE PAGE OR USING THE FORMAT BELOW. INCLUDE COMPANY NAME, ADDRESS, TEL#, CONTACT NAME, AND ADDRESS. Location #1 Delivery Contact Location #2 Delivery Contact Location #3 Delivery Contact Drive Credit Application Page 3 of 4

5 I represent that the above information is true and correct and is provided to induce Drive Medical and/or its designated lease/financing company to extend credit to Applicant. I authorize Drive Medical and/or its designated lease/financing company to make such credit investigation as Drive Medical and/or its lease/financing company deems necessary, including contacting the above banks, trade references, and obtaining credit reports. I authorize all banks, trade references, and credit reporting agencies to disclose to Drive Medical and/or its designated lease/ financing company any and all information concerning the financial and credit history of my company, and my self. I acknowledge that this application is for the extension of commercial credit only and any equipment leased will be used exclusively for commercial purposes. I have read the Terms and Conditions stated below and agree to all the terms and conditions. TERMS AND CONDITIONS: All invoices will indicate payment terms. Applicant hereby grants Drive Medical and/or its designated lease/financing company a perfected security interest in any and all goods purchased by Applicant from Drive Medical (and all proceeds thereof) to secure any and all obligations of Applicant to Drive Medical and/or its designated lease/financing company, including but not limited to the obligation of payment. Drive Medical and/or its designated lease/financing company is authorized to file and record any financing statements in its discretion. A service charge of 2% per month will be added to all amounts invoiced if not paid within terms. In the event Drive Medical and/or its designated leasing/financing company commences any action or actions, or otherwise seek to enforce this agreement against Applicant, Applicant consents to jurisdiction in New York and agrees to pay reasonable attorney(s) fees, court and other collection expenses incurred by Drive Medical and/or its designated leasing/financing company, whether or not suit is filed. Applicant agrees to pay sales tax on taxable items in states where a resale certificate is required and not provided. *****Note: Application must be signed by a principal or owner listed on page # 1 of this application regardless of terms requested.***** * * Owner Signature: Title: Date: Print Name: 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 (provided the applicant has the capacity to enter into a binding contact), because all of or part of the applicants income is derived from any public assistance program, or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The Federal Agency that administers compliance with this law concerning this creditor is the Federal Trade Commission, ECOA Compliance, Washington, D.C PERSONAL GUARANTY For benefit of (Name of Applicant Business) I residing at and (Owner/Guarantor Name) (Home Address) I residing at and (Owner/Guarantor Name) (Home Address) for good and valuable consideration, including the extension of credit to the Applicant identified on this application from which I will benefit, do hereby unconditionally guaranty and promise to pay in full on demand any and all obligations of Applicant to Drive Medical and/or its designated lease/financing company without regard to any claim of setoff, counterclaim or defense. I hereby waive notice of sale to Applicant, and of the terms thereof, and of non-payment or other default or dispute with Applicant. I hereby waive any right to a jury trial and consent to all renewals and modifications of terms of sale or credit. This is a continuing and irrevocable guaranty that shall remain effective and enforceable regardless of any change in the form, composition, nature, personnel or location of Applicant and I hereby subordinate any indebtedness of Applicant to me to that of Applicant to Drive Medical and/or its designated lease/financing company. I recognize that my individual credit history may be a necessary factor in the evaluation of this Guaranty and hereby consent to and authorize the use of a consumer credit report on me by Drive Medical and/or its designated lease/financing company, as a business credit grantor, from time to time as needed in the ongoing credit evaluation process. In the event Drive Medical and/or its designated lease/financing company should commence any action or actions, or otherwise seek to enforce this Guaranty against me, I agree to pay reasonable attorney(s) fees, court costs and other expenses incurred by Drive Medical and/or its designated lease/financing company in said action, whether or not suit is filed. I agree that a facsimile copy of this Guaranty shall be considered an original and admissible in a court of law to the same extent as the original document. This Guaranty shall inure to the benefit of Drive Medical and/or its designated lease/financing company and its successors and assigns and shall bind my heirs, executors, personal representatives, administrators and other successors. By: By: Owner/Guarantor Date Witness Owner/Guarantor Date Witness Revised 7/03/13 Drive Credit Application Page 4 of 4