New Account Credit Application

AOSS MEDICAL SUPPLY, LLC
Louisiana | Utah | Texas
New Account Credit Application Form
COMPANY INFORMATION
Company/Legal Name
Date

Month Day Year
Date
Billing Address
Street
City, State
Zip Code
Country
Shipping Address same as Billing? YES NO
Shipping Address
Street
City, State
Zip Code
Country
Type of Business:

Corporation Proprietorship Partnership LLC
Federal Tax ID No
Years in Business
DUNS Number
Medical Director's Name
State License No
State Licensed In
*Please attach a copy of Medical License*

Browse Files

Cancel of
AOSS Sales Representative:
CONTACT/OWNER/OFFICER INFORMATION
Main Phone

Area Code Phone Number
Main Fax

Area Code Phone Number
Finance Contact
Name
Email
example@example.com
Shipping Contact
Name
Phone Number

Area Code Phone Number
Fax

Area Code Phone Number
Email
example@example.com
Owner/Officer Contact
Name
Title
Phone Number

Area Code Phone Number
Email
example@example.com
Owner/Officer Contact
Name
Title
Phone Number

Area Code Phone Number
Email
example@example.com
BANK INFORMATION
Bank Name
Street Address
City, State
Zip Code
Country
Bank Phone Number

Area Code Phone Number
Bank Fax Number

Area Code Phone Number
BANK CONTACT INFO
Name
Title
Email
example@example.com
Phone Number

Area Code Phone Number
Account Number
Checking or Savings?

Checking Savings
BANK REFERENCE RELEASE AUTHORIZATION
I/We have requested credit from AOSS Medical Supply, LLC. Please accept my/our signatures below as authorization to release, either verbally or in writing, the credit information AOSS Medical supply requests from you regarding my/our banking relationship with you. Thank you.
Signature

Clear
Printed Name

First Name Last Name
Date

Month Day Year
Date
TRADE REFERENCES
Please provide 3 trade references from customers with whom you are currently doing business. You may attach your references on a separate page.
Reference 1
Company Name
Contact Name
Street Address
City, State
Zip Code
Country
Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number
Reference 2
Company Name
Contact Name
Street Address
City/State
Zip Code
Country
Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number
Reference 3
Company Name
Contact Name
Street Address
City/State
Zip Code
Country
Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number
CREDIT TERMS
If credit is extended, I/We agree to pay all debts incurred within the terms of sale. Interest shall be charged on all accounts not paid within 30 days at a rate of 1 1/2% per month or 18% annually. I/We further expressly agree to pay reasonable collection costs and/or attorney's fees incurred in the connection with the collection of this account, if it becomes delinquent. No returns will be accepted without an RGA. No claims will be allowed for shortages or errors in a shipment unless it was documented on the BOL and made within 10 days after receipt of goods.
Signature

Clear
Printed Name
Date

Month Day Year
Date
Please scan, email, or fax completed form to our Accounting Department at: Accounting@aossmedical.com | Fax: (318) 325-8299

Original must be mailed to AOSS Headquarters at:

Accounting Department 4971 Central Avenue Monroe, Louisiana 71203

We are here to serve you! Please, do not hesitate to reach out to our team at the information below:
Email: customerservice@aossmedical.com
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New Account Credit Application

New Account Credit Application

AOSS MEDICAL SUPPLY, LLC

Louisiana | Utah | Texas

New Account Credit Application Form

COMPANY INFORMATION

Billing Address

Shipping Address

CONTACT/OWNER/OFFICER INFORMATION

Finance Contact

Shipping Contact

Owner/Officer Contact

Owner/Officer Contact

BANK INFORMATION

BANK CONTACT INFO

BANK REFERENCE RELEASE AUTHORIZATION

TRADE REFERENCES

Reference 1

Reference 2

Reference 3

CREDIT TERMS