MedInfo, Inc.

Vendor Application Form

Business Contact Information

Company/Account Contact:

*Account Type: *Please Specify University Name:
*Tax ID/EIN/SSN:
*First Name: *Last Name:
*Email: * Phone:
Fax: Company Website:

Shipping Location

Shipping Address 1

First Name: Last Name:
Email: Phone:
*Shipping Service: *Shipping Account #:
*Address 1: Address 2:
*Country: *Zip:
*City: *State/Province:

Billing Address Contact

*First Name: *Last Name:
*Email: *Phone:
*Address 1: Address 2:
*Country: *Zip:
*City: *State/Province:

Order Details

*Will you be reselling our products: *Where:
*Store Address:
*Online Store Url:
*Tax Exempt: *Tax Exempt Number:
*Tax Exempt State:
Upload Tax Exempt Certificate:
Sales Tax Exempt Certificate

Please fill out and upload if you don't have Tax Exempt Certificate.

Terms & Conditions:

1. All invoices are due 30 days from the date of the invoice unless otherwise specified. 2. A Purchase Order Number is required for all incoming orders that are not prepaid. 3. If you choose to keep credit card on file, all invoices will be paid with credit card within 48 hours of the PO/Order being placed. An invoice confirmation email will be sent prior to charging the credit card on file. 4. Exchanges/Returns arising from invoices must be made within 30 business days. 5. All reselling locations must be included. Your resale of our items must be approved per location. If resale of any items occurs outside an approved location, action may be taken including, but not limited to: account suspension, legal action, copyright and/or patent infringement.
*Name: *Title:
* Date: