MAXMED LABORATORIES, INC.
8370 Juniper Creek Lane, #1
SAN DIEGO, CA 92126
TEL  (858) 271-8118
FAX (858) 271-5388
EMAIL: sales@maxmedlabs.com
www.maxmedlabs.com

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APPLICATION FOR NEW ACCOUNT
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Company Information:

Company Name: _____________________________________________

Shipping Address: ___________________________________________

Billing Address: ______________________________________________

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Fed Ex Account #: ___________________________________________

Phone Number: (_____)_________________________________________

Fax #: (_______)___________________________________________

IRS Tax ID#:  ________________________________________________

Seller's Permit # (Resale): _________________________________

Bank Information:

Bank:   ______________________________________________________

Account #: _________________________________________________

Address: ___________________________________________________

Contact: ___________________________________________________

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Phone #: (________)_________________________________________

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Trade Reference:

Company: ___________________________________________________

Contact: __________________________________________________

Account #: _______________________________ ___________________

Phone #: (________)________________________________________

Company: ___________________________________________________

Contact: __________________________________________________

Account #: __________________________________________________

Phone #: (________)________________________________________

Company: ___________________________________________________

Contact: ___________________________________________________

Account #: __________________________________________________

Phone #: (________)_________________________________________

I (we) promise to pay our account in full within 30 days terms. If this account is not paid as agreed a delinquency charge shall be computed at the rate 1.5% per month, 18% annum on unpaid balance.

I (we) know that all shipments are F.O.B. Origin, San Diego, CA 92126 and it is the buyer¡¯s sole responsibility to provide for insurance coverage. Shipments under refrigeration will be charged a $20 packing fee for each insulated foam container with ice bag and the $15 handling fee for each free sample requirement. A $10 export fee per overseas shipment will be charged for any item with custom value more than $2,500. A 25 USD (45 USD for international customers) bank service charge(s) each transfer will be added in wire-transfer payments.

You are authorized to contact any of the above references regarding our credit standing. I (we) have read the above terms and conditions and agree to abide by them.

 

Signature:

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(Authorized)

(Print Name)

(Title)

(Date)