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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