Charge Account Applications TTRX

Charge Account Application/Agreement for Tarrytown Pharmacy

Tarrytown Pharmacy is proud to offer In-House Charge Accounts for our customers and patients! Use the account to charge prescriptions, gifts, OTC items, and anything else you need at Tarrytown Pharmacy and get a convenient monthly bill!
I hereby request that you establish a Retail Charge Account for the following person:
Name of Patient :*

First NameLast Name
Address of Patient:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Mobile Phone Number:*
Please enter a valid phone number.
Home Phone Number:
Please enter a valid phone number.
Your Contact Email Address:*
example@example.com
Driver's License #:*
Social Security Number: *
Place of Employment*

Billing Contact
Will the patient be paying the bill or someone else?*

Patient will payAnother person will be handling payment
Billing Contact Name:*

First NameLast Name
Billing Contact Phone Number:*
Please enter a valid phone number.
Billing Contact Email*
example@example.com
Billing Contact Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Nearest Living Relative:
Do you have a nearest living relative?*

YesNo
Name of Nearest Living Relative :*

First NameLast Name
Address of Nearest Living Relative:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Main) of Nearest Living Relative:*
Please enter a valid phone number.
Place of employment of nearest living relative:*

Additional Changes to account
Would you like anyone else to be able to make changes to your account?*

YesNo
Name of Additional Account managers:*

First NameLast Name
Address of Additional Account managers:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Additional Account managers:*
Please enter a valid phone number.
Place of Employment of Additional Account managers:*
Driver's License Numbers of Additional Account managers:*
Social Security Number of Additional Account managers:*

Terms of Service and Agreement

Please read the following terms of service and agreement and sign below!
In consideration for your allowing me to make purchasers from you on credit, I understand that I will be billed monthly for all purchases and I agree to pay you promptly at your offices in Austin, Travis County, Texas, according to the terms listed in either paragraph A or paragraph B below, whichever option I choose:
1. I will pay in full the New Balance shown on each monthly statement on or prior to the next Billing Date indicated which will be approximately 30 days after the current Billing Date of the monthly statement. If I pay each monthly statement in full on or prior to the next Billing Date, I understand that I will not be charged a FINANCE CHARGE.
2. If I do not pay the entire New Balance on or prior to the next Billing Date, I agree to pay at least 20% of the New Balance, and if I do this I understand that a FINANCE CHARGE (18% ANNUAL PERCENTAGE RATE) will be added to my account to the next monthly statement (without deducting subsequent payments or other credits or adding subsequent purchases).
In consideration of your agreement to extend credit to me, I also agree to the following:
1. You may accelerate the maturity of any part or all of the amount I owe you if I am in default in the performance of any of my obligations in this agreement or if you, in good faith, believe that the prospect of my paying this account or performing under this agreement is impaired.
2. If I fail to pay you promptly as I have agreed to do in this agreement, I agree to pay your reasonable attorney’s fees, court costs and deposition fees which you incur if you have to hire an attorney to collect the money I owe you or to pursue any other action for the enforcement of this agreement.
3. I authorize you to check with any credit reporting agency or any of my references above as to my credit worthiness and to report to credit bureaus and other persons entitled to such information about what I have told you in this application and about my performance under this agreement.
4. If any of the provisions of this agreement is declared invalid, that provision only shall be void, but the rest of this agreement shall remain valid.
5. You may cancel my right to purchase on credit at any time without notice
6. I agree to notify you promptly if I move or change jobs
Notices: Any holder of this consumer credit contract I subject to all claims and defenses which the debtor could assert against the seller of goods or services obtained pursuant hereto or with the proceeds hereof, recovery hereunder by the debtor shall not exceed amounts paid by the debtor hereunder.

Notice to the Applicant:

Do not sign this agreement before you have read everything above or if it contains any blank spaces
You are entitled to a completely filled-in copy of this agreement
You may at any time pay your total indebtedness under this agreement
Keep a copy of this agreement to protect your legal rights
Please see accompanying statement for important information regarding your rights to dispute billing errors

I hereby acknowledge that I have received a copy of this agreement, completely filled in, before it was signed by me and that a copy was delivered to me at the time I signed it.
Applicant Name*

First NameLast Name
Date of Form Completion and Signature*

MonthDayYear
Date
Signature

Clear
Should be Empty:

Charge Account Application/Agreement for Tarrytown Pharmacy

I hereby request that you establish a Retail Charge Account for the following person:

Billing Contact

Nearest Living Relative:

Additional Changes to account

Terms of Service and Agreement