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Please complete this application on line, print, sign and fax SIGNED request to 215-942-9994. We will advise you by e-mail or telephone when your application has been processed.
 
Medi-Dose / EPS Account Application

 Facility Name:  
   Billing Address
 Address Line 1:  
 
 
 Line 2:
 
 City:  
 State:  
Postal/Zip Code:   
Country:   
   
 
Shipping Address (If Different)
Address Line 1:   
Line 2:   
City:   
State:   
Postal/Zip Code:   
Country:   
   Contact Information
Name:   
Phone:   
Fax:   
Email:   
   Facility Information
Type:   
FEIN #:   
   References
Trade Reference 1:   
Trade Reference 2:   
Trade Reference 3:   
Bank Reference:   
   Pennsylvania Applicants Only
PA Tax Exempt:   
Tax Exemption #:   
   Credit Terms (If Approved for Credit)
  Terms for approved accounts are strictly NET 30.   Accounts that are past due 45 days will be placed on credit hold.  Accounts that are past due 60 days will be required to PREPAY or COD orders.  In order to maintain our competitive pricing we must enforce the strict credit terms.  ABSOLUTELY no exceptions to these terms.   All sales, regardless of payment method, are subject to the terms of our published Sales Policy .

   Authorized Officer / Executive
Signature:   
Name:   
Title:   
Date:   

  Please complete this application on line, print, sign and fax SIGNED request to 215-942-9994. We will advise you by e-mail or telephone when your application has been processed.