SHIP TO INFORMATION Sample Clauses

SHIP TO INFORMATION complete if a designated shipping location exists. For multiple locations please attach a facility listing including the phone/fax information and the contact person’s name. By signing this application Applicant agrees to be financially responsible for amounts due and owing to Medline for all invoices and shipments to all of the facilities provided on a facility listing. Business Name GLN MASTER NUMBER Address City St Zip Phone Number Fax Number If Internet Business, please provide Website Address: Corporation Partnership LLC Limited Partnership Proprietorship Publicly Traded Non Profit # of Employees # of Beds # of Facilities Yrs in Business Owned Property Leased Property Are you part of a buying group? Group Name / Membership # Has Applicant(s), Parent or Business ever filed for Bankruptcy? NO YES (If yes, further information may be required) V. MANAGEMENT COMPANY / THIRD PARTY PAYER: Please Complete this section if another organization manages your payments. Company Name(s) Address City St Zip Phone Contact Person If Yes, Company Name Medline Acct Number Address City St Zip

SHIP TO INFORMATION complete if a designated shipping location exists. For multiple locations please attach a facility listing including the phone/fax information and the contact person’s name. By signing this application Applicant agrees to be financially responsible for amounts due and owing to SML MEDICAL SUPPLIES, INC. for all invoices and shipments to all of the facilities provided on a facility listing. Business Name GLN MASTER NUMBER Address City St Zip Phone Number Fax Number What portion of your revenue is dependent on Government or State funding such as Medicare, Medicaid, etc. Business Type (Hospital, Nursing Home, Surgery Center, Pharmacy, Laundry, HME Dealer, Internet, Scientific Products, etc) If Internet Business, please provide Website Address: Corporation Partnership LLC Limited Partnership Proprietorship Publicly Traded Non Profit # of Employees # of Beds # of Facilities Yrs in Business Owned Property Leased Property Are you part of a buying group? Group Name / Membership # Has Applicant(s), Parent or Business ever filed for Bankruptcy? NO YES (If yes, further information may be required) Are you Accredited? If so, please provide Accrediting Agency and Accreditation #, or attach a copy of Accreditation Certificate. Agency Accreditation # V. MANAGEMENT COMPANY / THIRD PARTY PAYER: Please Complete this section if another organization manages your payments. (Provide listing of managed entities) Company Name(s) ____________________________________________________________________________________ Address City St Zip Phone Contact Person Has the applicant had any prior history with SML MEDICAL SUPPLIES, INC., or any of its owners or managers ever operated the same type business? If Yes, Company Name SML MEDICAL SUPPLIES, INC. Acct Number Address City St Zip TERMS: Per our agreement all Invoices are due 30 days from the invoice date. A finance charge of 2% of the unpaid balance is automatically added to your account if payment is not received on the invoice due date. All claims for defective or damaged goods must be made within four (2) days after receipt of goods. Failure to notify SML MEDICAL SUPPLIES, INC. shall constitute acceptance of work, waiver of defect, damage or shortage. Customer consents to the jurisdiction of any state or federal court in Los Angeles, Orange and San Bernardino County, State of California. Customer will be liable for reasonable costs and legal fees incurred by SML MEDICAL SUPPLIES, INC. Industries or any affiliate thereof to assist in t...