emeraldmedicalservice.com - Manual wheelchairs, Power wheelchairs Scooters, Medical Supply

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Emeraldmedicalservice.com Credit Application

If you have any question please contact us using the address below

Emerald Medical Services
4913 Georgia Ave NW
Suite #1
Washington DC, 20011

Phone: 1-800-220-5911
Fax: 1-888-722-8819

email: support@emeraldmedicalservice.com

Business Information
Company Name:
d/b/a:
Address:
City:
State:
County:
Zip:
Phone:
Fax:
Date Business Established:
Equipment Location Address:
Federal I.D. #:
Business Structure:	CORPORATION PARTNERSHIP PROPRIETORSHIP LLC
Personal Information
(Owner / Officer)#1:
Title:
Address:
City:
State:
Zip:
Phone:
Social Security Number:
% Ownership:
Email:
(Owner / Officer)#2:
Title:
Address:
City:
State:
Zip:
Phone:
Social Security Number:
% Ownership:
Email:
Bank Reference
Bank Name:
Account No :
Contact:
Phone No:
Trade Reference
Supplier Name:
Account No:
Contact:
Phone No:
Vendor Information
Vendor Name:
Contact:
Phone No:
Equipment Description:
Equipment Cost:

The undersigned (1) authorizes AXIS Capital, Inc., its heirs & assigns to obtain a personal report on all principals & guarantors for credit purposes, & (2) authorizes the release to AXIS Capital, Inc. of all credit information it may request, including business & personal banking, mortgage, landlord, trade & lease information.

Signature: Title: Date:

* Please print your name in the Signature Section to electronically sign this form