Company Information
Application ID# : 3320739* = Required Field
Company Name Business Type Proprietorship Partnership Corporation LLC Non-Profit Other
Trade Name / DBA Account Type Optometry Practice Medical Practice Optical Shop Other
Business Address Building / Suite No.
City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip
Primary Phone Secondary Phone Fax
E-mail Address Web Site
Federal Tax Id# Length at Current Location Year Business Established
Previous Address Building / Suite No.
City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code
A/P Contact Name
A/P Phone A/P Email
Do you want your statements to go to another address? No Yes
Bill-to Name
Bill-to Address Building / Suite No.
Attention
Comments
Number of Office Locations Besides Main Address and Statement Address 0 1 2 3 4 5 6 7 8 9 10
Number of Principles Guaranteeing Account 1 2 3 4 5
Additional Office Locations
Location Name
Location Address Building / Suite No.
Primary Phone Secondary Phone Fax Number
Principals
First Name Last Name Middle Name
License Type OD MD Optician DO Other Home Phone
License Number License State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Terms and Conditions
Please check the boxes next to each line to agree.
Your Balance is due on the 20th of Each Month.
Any outstanding balances after the last day of the month will be assessed a 1.5% finance charge.
By completing the information below I (the undersigned) hereby agree to all the above terms and conditions and any and all other accounts not specifically named in this agreement of which I have an ownership in, and payment of sums due there under in the event of default, and hereby waives any right to claim release or exoneration by reason of any modification, amendment, or extension or notice thereof. This guaranty shall be a continuing and irrevocable guaranty and indemnity to C&E GP Specialists, Inc.
I have read, understand and agree to the terms and conditions.
Principal Initials Principal Full Name
