Account Application

MediPurpose® thanks you for your interest in applying for an account. Please fill out the following information. After submitting your application, MediPurpose® will review and contact you.

Applicant Contact Information

First Name *

Last Name *

Title *

E-mail *

Phone *

Fax

Mailing address same as company physical address

Mailing Address (if different than company physical address)

City

State (U.S. only)

ZIP Code (U.S. only)

Country

Billing Information

Accounts Payable Manager

Name *

Title *

E-mail *

Phone *

Fax

Mailing address same as company physical address

Mailing Address (if different than company physical address)

City

State (U.S. only)

ZIP Code (U.S. only)

Country

Shipping Information

Shipping address same as company physical address

Shipping address (if different than company physical address)

City

State

Country

Key Personnel

Materials Management

Name *

Title *

E-mail *

Phone *

Other

Name *

Title *

E-mail *

Phone *

Bank Reference

Financial Institution *

Contact

Phone *

Fax

Address *

City *

State (U.S. only)

ZIP Code (U.S. only)

Country *

Credit References

Reference #1

Company *

Contact *

Title *

Phone *

Address *

City *

State (U.S. only)

ZIP Code (U.S. only)

Country

Reference #2

Company *

Contact *

Title *

Phone *

Address *

City *

State (U.S. only)

ZIP Code (U.S. only)

Country *

E-Business Capabilities

Check all that apply:

EDI Internet Online Banking Other

Describe

Additional Information

Include any further information not requested elsewhere in application.

Enter the code

Past Due Invoice Note: Any invoice past due would be subject to attorney fees. It is agreed the venue for any lawsuits will be Gwinnet County, Georgia.