Credit Application Form

Company Application Information

*Company Name

*Website

*Email

*Phone

Fax

Billing Address

*Address

*City

*State/Country

*Zip

Shipping Address

Shipping Address:

(Check if same as Billing)

Address

City

State/Country

Zip

Parent Company (if applicable):

Parent Company Name:

*Website

Email:

Phone

Fax

Billing Address

City

State/Country

Zip

Business Contact Information

*Ownership:

Corporation

Partnership

Proprietorship

President

Vice President

Treasurer

*Accounts Payable Contact

*Accounts Payable Email

*Accounts Payable Phone

*Purchasing Contact:

*Purchasing Email

*Purchasing Phone

*Type of Business

*Year in Business

*Taxable

Yes (Please provide sale tax rate)

No - Sale Tax Exempt# (Please email certificate to AR@icbiomedical.com)

Sale Tax Rate

*Federal Tax ID

*DUNS#

VAT No

*Total Annual Sales

Bank Reference

Bank Name

Account #

Address

City

State/Country

Zip

Contact:

Phone#

*Contact's Email Address:

Trade Reference 1

Company

Account #

Address

City:

State-Country

Zip

Current Balance

Contact Name

Phone

Email

Open Since

Current Balance

Credit Limit

Trade Reference 2

Company

Account#

Address

City

State-Country

Zip

Contact Name

Phone

Email

Open Since

Credit Limit

Trade Reference 3

Company

Account #

Address

City

State-Country

Zip

Contact Name

Phone

Email

Open Since

Current Balance

Credit Limit

I hereby certify that the information contained herein is completed and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended.Furthermore, I here by a

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Company Application Information

Billing Address

Shipping Address

Parent Company (if applicable):

Business Contact Information

Bank Reference

Trade Reference 1

Trade Reference 2

Trade Reference 3