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 Parts & Service. 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 Parts & Service, LLC 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.

About DirectMed

MRI & CT Parts, Imaging Systems and MRI Coils. DirectMed is your fastest multi-modality vendor for medical imaging replacement parts, repairs, used systems and field service solutions. We have decades of team experience in servicing medical imaging equipment and helping extend the life of your MRI or CT machine.

65,000+ Used MRI & CT Parts in Stock. Another 4,500+ MRI Coils for sale are ready to ship today to get you online and scanning. ISO 13485:2016 Registered. Available 24hr 365 Days a Year. Americas largest MRI Coil inventory. Engineering and technical support are California Based and highly experienced.
Call for a Quote, (855) 463-3727

DirectMed Parts & Service Subsidiaries include LBN Medical & ScanMed

Credit Application: