Customer Credit Application

Legal Company Name(Required)

Type of Business(Required)

Corporation

LLC

Sole Proprietorship

Date Business Started(Required)

UEID (D&B Number)(Required)

Federal Tax ID(Required)

Business Address(Required)

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

Phone(Required)

Website

POC for Invoices

Name(Required)

First Last

Title(Required)

Email(Required)

Phone(Required)

Address for Invoices

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

Bank Reference Information

Bank Name(Required)

Bank Point of Contact Name(Required)

Bank Point of Contact Phone(Required)

Trade Reference 1

Company(Required)

Name(Required)

First Last

Title(Required)

Phone(Required)

Trade Reference 2

Company Name(Required)

Name(Required)

First Last

Title(Required)

Phone(Required)

Trade Reference 3

Company 1(Required)

Name(Required)

First Last

Title(Required)

Phone(Required)

Authorization To Release Information

To establish a line of credit, I hereby authorize our trade references and bank to release to Medical Points Abroad, Inc.., all necessary information.

Signature serves as a release to conduct a routine credit check obtaining information from trade references, bank, any party whom customer does business with, and credit reporting agencies. ALL INFORMATION OBTAINED BY MEDICAL POINTS ABROAD, INC , WILL BE HELD CONFIDENTIAL.

The above information is provided for extending credit by Medical Points Abroad, Inc, to our company. To the best of our knowledge and belief, the information is complete and accurate and may be relied upon in making your credit decision. The company agrees to pay all bills when due, including reasonable collection and attorney’s fees, if collection is required.

Print Name and Title(Required)

Authorized Officer Signature(Required)

Personal Guarantee

I/We jointly and severally do hereby agree to personally guarantee, absolutely and unconditionally, the payment of any and all debts incurred by the Purchaser when payment for the goods and services shall become due. It is further understood that this personal guarantee is to apply to any and all goods and services sold to Purchaser during the period beginning with the date of this credit agreement and extending to a time when written notice of the cancellation hereof shall have been received and accepted by the Medical Points Abroad, Inc.. This agreement shall not be waived or otherwise impaired by an extension of time for payment to Purchaser, or by the ceasing of Purchaser to continue to operate.

Signature(Required)

Printed Name and Title(Required)

Signature

Printed Name and Title