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Credit Inquiry

VIEWS: 31 PAGES: 2

  • pg 1
									__________________________________________________________________________________________
  25 Bloomingdale Road 2nd Fl Hicksville, NY 11801 Phone: 866-575-2884 Facsimile: 516-927-0109

CUSTOMER ACCOUNT FOR M
COMPANY PROFILE:
Name of Company:
Current
address:
City:                         State:                                             ZIP Code:
Telephone:                                                            Fax:
Please Check One Below:
Proprietorship:               Partnership:             Corporation:                      Other:
If checked other,
please specify:
IF CORPORATION, OFFICERS’ NAMES
President:
Buyer:
Payables:
Date Business Established:                             How long at present address:
No of employees:                                       Resale No:
Dun & Bradstreet
No:
TRADE REFERENCES
(1) Name:                                             Company:
Tel No.                                              Fax No.
Current address:
City:                         State:                      ZIP Code:
(2) Name:                                            Company:
Tel No.                                              Fax No.
Current Address:
City:                         State:               Zip Code:
BANK REFERENCES
Name of Company:
Contact Person                                       Phone:                                  Fax:
Address:
City:                         State:                          Zip Code:
Type of Account: (Please check one)    Checking:                      Savings:
Account Number:
I authorize Health Management Solution to verify the information provided on this form as to obtain
any credit information from commercial or consumer credit information.


Please Print Name:                                                               Title            Date


Authorized Signature:                                                                             Date



                          hms IT ® - Total Healthcare Technology Solutions.
__________________________________________________________________________________________
   25 Bloomingdale Road 2nd Fl Hicksville, NY 11801 Phone: 866-575-2884 Facsimile: 516-927-0109




Payment Requirements


To Whom It May Concern:

Health Management Solutions requires all payments within Net 20 days of the invoice date. To
ensure payment we require a credit card which will be used only if the invoice falls delinquent by
Net 45 days or longer. In order to process the request for any services that we offer we must have
a valid credit card on file.

Date:
Name of Company:
Credit Card Billing Address:
City:                                              State:                    Zip:
Name of Cardholder:
Type of Credit Card    (Please Check One Below)
American Express:                Master Card:                   Visa:
Credit Card Number:                                             Exp. Date:


Authorized Signature:                                                         Date:




CONFIDENTIALTY NOTICE: This document contains confidential information belonging to
the above stated company. The information is intended only for the use to process delinquent
invoice payments owed to Health Management Solutions.




                       hms IT ® - Total Healthcare Technology Solutions.

								
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