 MD  DO  PA  CRNP  RN  LPN  CNA

NEW CUSTOMER ACCOUNT DATA FORM
Instructions:
A) To expedite your account set up, please respond to all of the following questions.
Kindly complete all of the following pages so that accurate information is on file at Pocket Nurse®
B) Return the completed form by fax to 1-800-763-0237.
Attn: Account Department: New Accounts [email protected]
cc:
1. New Customer Information
Organization
Federal EIN
Contact Name
Title
Phone (
)
Fax (
Email Address
)
Website
2. Please describe the degrees your school provides. Check all that apply:
 MD
 DO
 PA
 CRNP
 RN
 LPN
 CNA
 RT
 PT/OT
 CRNA
 MA
 OTHER
3. What is your tax status?
If Exempt, are you:
 Exempt
 Non-Exempt
 Educational
If Exempt, please fax your tax
exemption or resale certification
with this form.
 Government
 Charitable/Not for Profit
Pocket Nurse® is a
Pennsylvania corporation with
a nexus only in Pennsylvania.
Therefore, we are only
licensed to collect and remit
Pennsylvania Taxes.
4. Billing Address
Invoice Contact
School Name
Address 1
Address 2
State
City
Phone (
Email
)
Ext
Zip/Postal Code
Fax (
)
5. Shipping Address
Shipping Contact
School Name
Address 1
Address 2
State
City
Phone (
)
Ext
Zip/Postal Code
Fax (
)
Email
6.Purchasing
Purchasing Name
Phone (
)
Ext
Email
7. Will this be a one-time purchase?
 Yes
 No
If not, what is the anticipated annual purchase amount?
8. Is your organization EDI compatible?
 Yes
 No
EDI Contact
Phone (
)
Email
NEW CUSTOMER ACCOUNT CREDIT APPLICATION FORM
Dunn & Bradstreet Number
Can financial statements be available?
 Yes
Controller
Controller Email
ACCOUNTS PAYABLE CONTACT (Required)
Accounts Payable Contact
Accounts Payable Email
Accounts Payable Phone (
)
Accounts Payable Fax (
)
 No
Fax (
)
Trade Reference 1 (Required)
Name
Address
City
Phone (
State
)
Zip/Postal Code
Fax (
Ext
)
Credit Contact
Trade Reference 2 (Required)
Name
Address
City
Phone (
State
)
Zip/Postal Code
Fax (
Ext
)
Credit Contact
Trade Reference 3 (Required)
Name
Address
City
Phone (
State
)
Zip/Postal Code
Fax (
Ext
)
Credit Contact
Bank Reference
Name
Address
City
Phone (
State
)
Zip/Postal Code
Fax (
Ext
)
Credit Contact
PLEASE NOTE: This is an application to establish an account with Pocket Nurse®. It is not a guarantee that you will be accepted or that an account
has been established. This is subject to the Terms and Conditions of Pocket Nurse®.
Guarantee
In consideration of credit being extended by Pocket Nurse® Enterprises Inc. to the above names for merchandise to be purchased whether applicant be an individual
or individuals, a partnership, a corporation or other entity, the undersigned guarantor or guarantors each hereby contract and guarantee to Pocket Nurse® the faithful
payment, when due, or all accounts of said applicant for purchases made. The undersigned guarantor or guarantors each hereby expressly waive all notice of
acceptance of the guaranty, notice of extension of credit applicant, presentment, and demand for payment of applicant, protest and notice to undersigned guarantors of
dishonor or default by applicant or with respect of any security held by Pocket Nurse® extension of time of payment to applicant, acceptance of partial payment comprise
all other notices to which the undersigned guarantor or guarantors might otherwise of dishonor or default by applicant or with respect of any security held by Pocket
Nurse® extension of time of payment to applicant, acceptance of demand for payment under this guaranty. Any revocation of this guaranty shall be in writing and
delivered to Pocket Nurse® Enterprises, Inc., 610 Frankfort Road, Monaca PA 15061 SIGNATURE
NAME (Print)
TITLE
DATE
FOR INTERNAL USE ONLY
Ship via
Payment Terms
Credit & Collections
Tax
Notes
Sold to
Ship to
Bill to

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