SPS New Account Request Form

* - required field

Trade/Business Name *

Type: *

Partnership

Corporation

Proprietorship

LLC

Billing Address

Billing Address *

City *

State *

Zip Code *

Billing Address is the same as Shipping Address. *

Yes

No

Shipping Address

Shipping Address *

City *

State *

Zip Code *

Add an additional shipping address? *

Yes

No

Shipping Address 2

City

State

Zip Code

To add additional shipping addresses, please contact your sales account manager.

Contact Information

Contact First Name *

Contact Last Name *

Title *

Work Phone *

Mobile Phone

Email *

Fax Number

Accounts Payable Contact First Name *

Accounts Payable Contact Last Name *

AP Email *

AP Phone Number *

Business Information

Business License

Year Established

Fed ID#

How did you hear about SPS? *

Other

What type of services does your company provide? *

What purchasing methods do you use?

Buying Groups

Distributors

Direct from Manufacturer

Other Other

Total anticipated spend for 12 months from SPS *

Preferred payment method? *

Net 30 day credit terms

Check by phone

Credit card

*Requires authorization for credit check or two trade references preferably within medical field

_____________________________________________________________________________________________________

Owners/Officers Information

Name *

Title *

City *

State *

Zip Code *

_____________________________________________________________________________________________________

Filed for bankruptcy protection? *

Yes

No

If Yes, please explain:

Claim Sales Tax Exemption? *

Yes

No

Upload Tax Exempt Certificate *

If yes, what states are sales tax exempt? *

Bank Information

Bank Reference Name *

Bank Reference Contact *

Bank Reference Phone Number *

Account Numbers

+-

Trade References

Company Name

Phone Number

Account Number

Address

City

State

Zip Code

Authorized Purchasers

Name

Title

Payment Terms

As an SPS account holder, you agree to payment within your account’s terms. These terms will be based on SPS’ credit review, and may change based on account payment history or other factors. Past due invoices are subject to a finance charge of 1.5% per month. Applicant agrees that should it be necessary to employ a collection agency or attorney to collect monies due, applicant will be responsible for all reasonable costs of collection. As an inducement to grant credit, the undersigned authorizes and releases all businesses, banks, and persons identified on this application to furnish any and all information requested by SPS or its representative, by telephone or written correspondence. The undersigned further warrants that the information provided is true and correct. *

I acknowledge that I have read the above terms.

As of January 1, 2019, all invoice and statements will be sent via email. If you'd like to receive mailed or faxed invoices, please call 800-767-7776 x6. *

I acknowledge.

Authorized Signature for Payment Terms *

clear

Date * +

Authorization for Credit Check

First Name *

Middle Initial *

Last Name *

Street Address *

City *

State *

Zip Code *

By signing this application, I authorize SPS or its agent to investigate my business credit and financial records including my bank records. As part of such investigation, I authorize SPS to request and obtain credit reports on my business in connection with the opening, monitoring, renewal and extension of this and other accounts with SPS. If I request, SPS will tell me whether my business credit report was requested and, if so, the name and address of the credit-reporting agency that furnished the report.

Authorized Signature for Credit Check *

clear

Date +

Authorization for Personal Guaranty

First Name

Middle Initial

Last Name

Street Address

City

State

Zip Code

By signing this SPS application, I acknowledge that I have personally guaranteed the debts and obligations of my business and agree that I am personally obligated to perform all of the terms of and make all payments to SPS required by the agreement of which the application is a part.

Authorized Signature for Personal Guaranty

clear

Check here to receive emails about new products, promotions, and events.

Prosthetics	Orthotics	Pediatrics	Pedorthics
Occupational Therapy	Physical Therapy	Footwear