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. All Customers are required to keep a valid credit card on file. All Credit Card payments are subject to a 3% processing fee. Check, ACH, Debit Card and Wire Transfers are accepted with no processing fees. Customer must pay within 30 days of statement date. If payment isn’t made within 30 days, the credit card on file will be charged. Customers 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: If Customer identifies any discrepancy, error, or issue with the goods or services provided by Peterson Dental Laboratory, Inc., Customer must provide written notice detailing the discrepancy within thirty (30) days of receipt of the applicable invoice. Claims submitted after the thirty (30) day notice period may not be eligible for credit or adjustment. 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 will be paying by check. I will be setting up ACH or Wire Transfer I will paying by credit card either through Bill & Pay or by calling in before 30 day mark, I acknowledge, my card will be charged if I don’t pay my statement balance by the 30 day mark License #(Required)Guarantor (Customer) Signature(Required)TYPING YOUR FULL NAME IN THE FIELD BELOW CONSTITUTES A BINDING SIGNATURE ON THIS DOCUMENTConsent I agree to the privacy policy.
