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New Accounts

To establish an account, please complete our Online New Account Information Form or print it and fax it to us at (954) 835-0301.

Online New Account Information Form
Date:
Company Name:
Pharmacy or Physician's License #
Bill To Address:
Ship To Address:
Phone:
Fax:
Type of Business: (Sole Owner, Partnership, Corp.)
Date of Incorporation:
Florida Annual Resale Certificate No.: (if applicable please fax a copy)

Purchasing Contact:
Purchasing Email:
Purchasing Phone:

Accounts Payable Contact:
Accounts Payable Phone:
Accounts Payable Fax:
Accounts Payable Email:

Bank:
Bank City, State:
Bank Phone:
Bank Fax:
Primary Account #:
Secondary Account #:

I authorize Wolf Medical Supply, Inc. to verify the status of our corporate bank account and to obtain information pertaining to our application for a line of credit with Wolf Medical Supply. All information supplied will be kept in strict confidence.

Trade References:		In order to consider your application we must receive 3 trade references, please provide us with at least 6 trade references as some companies do not offer credit references. (Please include Co. Name, Account No., Phone and Fax Number)

Company Name:		Company Name:
Account #:		Account #:
Phone:		Phone:
Fax:		Fax:

Company Name:		Company Name:
Account #:		Account #:
Phone:		Phone:
Fax:		Fax:

Company Name:		Company Name:
Account #:		Account #:
Phone:		Phone:
Fax:		Fax:

Phone: 800.335.9653 | Fax: 954.835.0301 | Email: orders@wolfmed.com