Order Online: New Client Application

 

Fill out the information below and we will contact you immediately.

   
 
 

Legal Name

 

 

Trade Nam

 

 

Tax ID

 

 

Business Type

 

 

Billing Address

 

Street

 

 

City

 

State

Zip

 

Shipping Address

 

Street

 

 

City

 

State

Zip

 

Accounts Payable Contact

 

Name

 

 

Phone

 

 

Receiving Contact

 

Name

 

 

Phone

 

 

Bank Reference

 

Bank Name

 

 

Contact Name

 

Phone

       
 

References

 

Supplier

 

 

Contact

 

 

Phone

 

       
 

Supplier

 

 

Contact

 

 

Phone

 

       
 

Supplier

 

 

Contact

 

 

Phone

 

       
 

*****State license required for all accounts. *****

Assignment: By clicking below, I hereby authorize the release of any required credit information to Prodigy Health Supplier from banks, national credit reporting agencies, commercial or consumer related entities. Additionally, we acknowledge that in the event that we are granted credit with Prodigy Health Supplier Corporation, purchases are made, and a payment has not been made when requested, that our account will be considered in default and all monies due shall be subject to a 1.5% per month late fee and any related collection, court and/or attorney fees permitted by law.