Credit Application

Medgluv Credit Application

On-line Credit Application
Select this option if you prefer to fill out our Credit Application below using a secure server.

Off-line Credit Application (download)
Select this option if you prefer to fill out our Credit Application off-line. You will be able to download the application in PDF format. Just print the file to your printer, fill it out and fax or mail it back to us. If you do not have a PDF reader, download one now by clicking on the Adobe Acrobat icon below.

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To  download it from Adobe, click  here.

Medgluv On-line Credit Application

Business Information

Company Name:
Billing Address:
City:
State/Province:
Zip/Postal Code:
Country:
Shipping Address: (If different from above)
City:
State/Province:
Zip/Postal Code:
Country:
Phone:
Fax:
Federal Tax ID:
FL Sales Tax Resale #: (Annual Certificate Must Accompany Application)
Years in Business:
Nature of Business:
Date Business Started:
Type of Entity: (Please check one)	Corporation Partnership Sole Proprietorship Other
If 'other' above:
Purchase Orders Required?: (Please check one)	Yes No
Purchasing Manager:

Bank Information 1

Bank Name:
Account #:
Phone:
Address:
City:
State/Province:
Zip/Postal Code:
Country:
Contact Name:

Bank Information 2

Bank Name:
Account #:
Phone:
Address:
City:
State/Province:
Zip/Postal Code:
Country:
Contact Name:

Credit References

Business Name:
Contact Name:
Phone:
Fax:

Any and all information is held in the strictest confidence.

Owner/Officers

Name:
Title:
SSN:
Home Address:
City:
State/Province:
Zip/Postal Code:
Country:
Home Phone:
FL Drivers License #:
Other Drivers License #:
Other Drivers License State:

Open Account Terms and Conditions

Bank Name:
Account #:
Contact Name:
Phone:

Terms: Invoices are payable within 30 days of invoice date. Proof of delivery must be requested within 21 days of invoice date on all normal delivery, express delivery must be requested within 10 days of invoice date.

A finance charge of 1.5% per month will be assessed on all balances outstanding past terms. Returned merchandise will be refunded the full amount for unopened boxes within a period of 14 days.

The undersigned assures that the information contained above is true and correct; and furthermore, hereby authorizes the release of information from the listed credit references and banking institution to MedGluv Inc. In consideration of Medgluv Inc. extending credit to the above applicant the undersigned personally guarantees the payment of any and all future obligations which may be owed to MedGluv Inc. as well as interest and reasonable Attorney fees. Venue and jurisdiction for all actions necessary to enforce this agreement shall be held in Broward County, Florida.

BY COMPLETING AND RETURNING THIS APPLICATION TO MEDGLUV INC. THE APPLICANT REPRESENTS THAT ALL OF THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND CORRECT. THE APPLICANT WILL ALSO AGREE TO NOTIFY MEDGLUV OF ANY CHANGE IN COMPANY OWNERSHIP OR MANAGEMENT

I Agree to the Terms and Conditions Stated Above

Name:
Title:
Date: