Credit Application:

Option 1. Faster Approval. Fill out the online form below, parts 1 & 2. Submit for Sales and Finance to review your application.

Option 2. Download the Fillable PDF, return it to your account manager. To Save, Right Click, “Save Link As”. PDF Credit Application – Fillable – Complete & Return

Credit Application

Apply for Credit from DirectMed Imaging. Contact your Account Manager if you have questions.

Step 1 of 2

Business Contact Info

Name:

Company:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email:

Phone:

Date Business Commenced:

Business Type

Pick One.

Federal ID #

Resale #:

Billing Information

Primary Billing Address:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How long at current address?

Telephone:

E-mail:

Accounts Payable Contact

Name

First Last

Phone

Business/Trade References

Company 1

Business reference.

Company 1 Name(Required)

Contact Name(Required)

Contact Phone(Required)

Contact Email(Required)

Company 1 Location & URL

City State / Province / Region

Website

http:// or https:// Required Format

Company Relationship (Vendor, Supplier, etc)

Company 2

Business reference.

Company 2 Name(Required)

Contact Name(Required)

Contact Phone(Required)

Contact Email(Required)

Company 2 Location & URL

City State / Province / Region

Website

http:// or https:// Required Format

Company Relationship (Vendor, Supplier, etc)

Company 3

Business reference.

Company 3 Name(Required)

Contact Name(Required)

Contact Phone(Required)

Contact Email(Required)

Company 3 Location & URL

City State / Province / Region

Website

http:// or https:// Required Format

Company Relationship (Vendor, Supplier, etc)

Bank Reference

Bank Contact Name:

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Agreement

1. All invoices are to be paid 30 days from the date of the invoice, unless otherwise noted. 2. Claims arising from invoices must be made within seven working days. 3. By submitting this application, you authorize DirectMed Imaging to make inquiries into the banking and business/trade references that you have supplied.

Name

First Last

Title

Date

Upload - W9 & Resale Cert

W9 required. Resale cert needed if you resale parts.

Files - Upload W9(Required)

Max. file size: 128 MB.

Files - Upload Resale Cert.

Max. file size: 128 MB.

Credit Application: