Account Setup Form - US Endoscopy

5976 Heisley Road
Mentor, Ohio 44060
Customer Service: 800.769.8226
FAX: 440.639.4495
www.usendoscopy.com
Account Information
ACCOUNT SET‐UP/
RENEWAL FORM
Customer Number Credit Limit
Customer Name
Fed. Tax ID No. Corporation? [Y / N]
DUNS No. State of Incorporation
Billing Address
City State Zip
Sales Tax Rate
County
Tax Exempt [Y/N]
Identify GPO/IDN or
contract affiliation
**If Yes, then attach an exemption certificate
Shipping Addresses
(Include information on additional shipping addresses on a separate sheet)
Facility Name/Contact
Shipping Address
City State Zip
Financial References
Bank References
Other References
Bank Contact
Accounts Payable
Nurse Manager
Purchasing Dept.
Number of Beds
Contact Information
Name Email Phone No. Fax No.
Facility/Product Usage Information
GI Procedures Per Year
Ordering Information
US Endoscopy can accept orders by approved customers via telephone, fax, or through US Endoscopy’s
Online Store. (The US Endoscopy Online Store is only available for domestic (US) orders. Identify the
methods that you will use to place orders:
Order Method
Y/N
Telephone
Fax (With Purchase Order Number)*
Email (With Purchase Order Number)*
US Endoscopy Online Store*
Do you require a valid purchase order number?
[Y / N]
FS 1169 Rev C

1. Remit to address: US ENDOSCOPY
Accounts Receivable
5976 Heisley Road
Mentor, Ohio 44060
Credit Terms and Conditions
2. The Terms and Conditions of Sale that are located on US Endoscopy’s website (www.usendoscopy.com) will apply
to all product sales unless there is a separate agreement signed by US Endoscopy and Customer.
3. Credit terms are Net 30 days payable by check or ACH. All invoices over 60 days are past due and subject to a
1.5% finance charge per month.
4. US Endoscopy reserves the right to not ship products to accounts that are past due or that exceed the established
credit limit.
5. US Endoscopy reserves the right to make shipments on a COD basis until a past due account has been made
current.
6. All prices listed are F.O.B. shipping point, freight prepaid and added to the invoice. Standard shipment protocol
is FedEx Economy Two‐Day. Applicable taxes will be added unless there is an exemption number or certificate on
file.
7. US Endoscopy, in its sole discretion, may change its credit policies at any time. Upon acceptance of this
application and the issuance of an open line of credit, you agree to abide by US Endoscopy’s credit policies.
Applicant hereby agrees that the person signing below has the authority to submit Account Set‐
Up/Renewal Form and obtain credit from US Endoscopy. Applicant further provides permission for
US Endoscopy or its agents to contact the references listed above, or any other source, to obtain
credit information. The creditor, bank, lending institution or other source has the Applicant’s
permission to furnish US Endoscopy with any and all information requested.
Signature of
Date
Officer, Partner or
Owner
Printed Name
Title
Please allow two (2) business days for processing after the form is received. US Endoscopy’s normal business hours are Monday through Friday,
8am to 6pm EST. In the event that a form is submitted during a weekend or holiday, the form will be processed beginning on the following
business day.
Date submitted:
FOR US ENDOSCOPY USE
Approved by:
Name:
Signature:
Date:
FAX THIS ACCOUNT SET‐UP/RENEWAL FORM TO 440.639.4495
FS 1169 Rev C