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FOR USA GUESTS ONLY

1. REQUESTED CREDIT AMOUNT

$
Financial Statements required on credit limits of US $5,000 or more

2. COMPANY

Name	Address
City	State
Zip Code	Phone
Fax	Incorporated? Yes No
Date Started Business	Federal EIN Number

3. OFFICERS/OWNERS/PARTNERS

Name	Title	Phone	SS #


If not incorporated, owner/partner must insert Social Security number

4. PRESENT MAJOR SUPPLIERS

(Minimum five references since not all references will respond)
Name	Address	Phone	Acct. #

5. BANK REFERENCE

Name	Address	Phone	Acct. #



As part of this application for credit, we grant permission to contact consumer credit reporting agencies, commercial credit agencies and any or all of the credit references listed above, together with any other references which these agencies may provide. We further agree that if said account is not paid within thirty (30) days, the undersigned will be liable for all costs incurred for collection of the account including attorney's fees. We understand that failure to pay within thirty (30) days could result in a change of our credit status. We further agree to pay a reasonable service charge on invoices not paid within terms.


Name and Title*	Date

NOTE: This application cannot be processed until all information is completed. *Must be an officer if incorporated.

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Phone: 800-726-8367 (USA) | 760-727-5600 (Outside USA) | 760-727-4220 (Fax)
Email: information@bmls.com (general) | sales@bmls.com (Order Information)
BioMedical Life Systems, Inc. - P.O. Box 1360, Vista, California USA 92085-1360
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