Wholesale Credit Application
Tel: 1-888-645-2055 Fax: 1-877-805-7359 Email: wholesale@capitalmedicalsupply.ca
Signing Officer Full Name
*
First Name
Last Name
Signing Officer's Title
*
Legal Name of Business:
*
Tax ID Number
*
Business Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Business
*
Dental Clinic
Doctor / HealthCare Practitioner
Medical Clinic
Medical Supplies Store
Pharmacy
Other
Legal Form Under Which Business Operates
*
Corporation
Partnership
Sole Proprietorship
Is this company a Subsidiary or Division of a parent company?
*
Yes
No
Back
Next
Parent Company Information
Name of Parent Company
Is the Parent company responsible for Business related transactions?
Yes
No
Back
Next
Financial Information
Banking Information
*
Bank phone number
*
Please enter a valid phone number.
Back
Next
Trade References
References
*
References
References
Signing Officer's Signature
Clear
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: