Credit Agreement Form Credit Agreement The understanding herby applies for trade credit from Peterson Dental Laboratory. Office Location InformationPractice Name(Required)Dentist Name(Required)Contact(Required)Phone(Required)Address(Required)AddressCity(Required)CityState(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStateZIP(Required)ZipBilling InformationPractice Name(Required)Dentist Name(Required)Contact(Required)Phone(Required)Address(Required)AddressCity(Required)CityState(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStateZIP(Required)Zip TERMS AND CONDITIONS In consideration of Peterson Dental Laboratory, Inc. extending credit to Customer, Customer agrees to the following terms and conditions. These terms and conditions control over any conflicting provisions contained in any contracts, documents, purchase orders, confirmations, or the like from the Customer. To ensure understanding and acceptance of Peterson Dental Laboratory’s terms and conditions, we require all new accounts to complete and sign this form and forward it to our Accounts Receivable Department. If we do not receive this Credit Agreement, any new cases will be billed based on a collect on delivery (COD) basis until the credit agreement is received. Payment: Customer shall pay the fee and all other charges associated with the case 30 days after statement. A late fee of 2% will be applied per month to unpaid balances. Buyer shall pay all costs incurred by Peterson Dental Laboratory in collecting any amount due, including all reasonable attorneys’ fees and a $30.00 handling charge for any returned checks. The undersigned agrees that this agreement is made in the State of Florida and that Palm Beach County, Florida is a proper venue for any action to collect money owed to Peterson Dental Laboratory, Inc. by the Customer. Nonconforming Goods: Claims on any goods or services provided by Peterson Dental Laboratory, Inc. to Customer do not conform to the description on the invoice will not be credited unless Customer gives written notice to Peterson Dental Laboratory within 30 days after the Customer’s receipt of the invoice. Peterson Dental Laboratory, Inc. will repair, or remake work invoiced no more than 12 months ago to the Customer’s satisfaction. The charges will be agreed upon at the time of the repair, remake, or services. Principal Practice: The principal practice and/or owner of group, will be ultimately responsible for all invoices incurred from any affiliate dentist working for the principal practice group. If practice does not wish to be responsible for affiliate dentist, then a separate Credit Agreement and Warranty & Return Policy will need to be completed before account will be issued credit. The account will remain on COD status until forms are received by the lab. Authorization to obtain Credit Information: Customer expressly authorizes Peterson Dental Laboratory, Inc. to seek and obtain credit information from all sources, including but not limited to, all credit bureaus and credit reporting agencies. I have read Peterson Dental Laboratory’s Credit Agreement and accept the terms and conditions. Please select one of the following payment options:(Required) I would like to pay by check. I would like to have my credit card automatically charged each month (please complete Pre-Authorization form). I would like to pay by credit card online or by phone. License #(Required)Guarantor (Customer) Signature(Required)TYPING YOUR FULL NAME IN THE FIELD BELOW CONSTITUTES A BINDING SIGNATURE ON THIS DOCUMENT
