Credit Account Application

Medisa

Credit Application Form

General Business Information

Complete all fields.

General Business Information
Street Address
City
State
Phone #
Web Address
Type of Business
Are Purchase Orders Used?

Name of Owners, Partners, or Officers and Titles If Incorporated

Complete all fields and provide at least one owner, partner or officer.

Name Name
Title Title
Phone # Phone #
Email Email

Trade Reference Information

Please provide information of at least three trade references.

Name Name
Contact Person Contact Person
Phone # Phone #
Email Email
Name Name
Contact Person Contact Person
Phone # Phone #
Email Email
This application is submitted for the purpose of obtaining credit with Medisa and is warranted to be true. By signing this application the undersigned acknowledges that he/she is authorized to execute this application and to obligate the company to make payment in full for all amounts due according to invoice on or before the net due date. Additionally, the undersigned will be responsible for all collection costs and attorney fees, with or without lawsuit, in order to collect any delinquent moneys. The undersigned hereby authorizes Medisa Pty Ltd, to make such inquiries (corporate/personal) as are necessary to obtain credit information and authorizes the bank(s) of record to release information regarding accounts.

Conditions of Sale:

The tender of the goods in this order "the goods" is made under the condition that acceptance of the goods by the buyer of his agent shall constitute confirmation by the buyer of his acceptance of an offer by the seller to sell the goods subject to the following conditions:

  1. The parties agree that the property in the goods sold shall not pass from seller to the buyer, until the seller receives from the buyer full payment of the purchase price in cleared funds. Until such payment is made, the seller may at any time, without notice by itself or through any authorised officer, enter upon the premises of the buyer, and regain possession of part or all of the goods supplied, and in such event, the seller shall issue to the buyer a credit note in respect of such goods, provide they are in good and saleable condition. The buyer shall not be entitled to make any claim for damages or compensation against the seller in the event that the seller regains possession of the goods due to non-payment.
  2. At all times, the seller or its assignee shall be entitled to recover from the buyer the value of the goods (as invoiced) as a liquidated sum.
  3. Payment terms net 30 days from date of receipt of goods.
  4. No claim allowed for damages or shortages after seven days from the date the receipt of goods.
  5. No credit claims will be accepted without prior approval.
  6. Any expenses, costs or disbursements incurred by MEDISA Pty Ltd in recovering any outstanding monies including debt collection fees and Solicitors costs shall be paid by the customer, providing that those fees do not exceed the scale charges as charged by the Debt Collection Agency/Solicitor plus any out of pocket expenses.
  7. This agreement is governed by the law in force within the states of NSW, QLD, SA, TAS, WA, NT, ACT & VIC.

Signature

Please sign below before submitting.

Application submitted successfully!