Swede-O New Dealer Application

Swede-O Inc.
2010 Credit / New Dealer Application

Company Name

Contact Email Address

President / CEO Accts. Payable Contact

Mailing Address

Shipping Address

Telephone Fax Web Address

Number of Years in Business Total Annual Sales Revenue

PLEASE BE SURE TO SUPPLY FAX NUMBERS FOR BANK & REFERENCES

Credit

Bank Name Contact Name

Address Telephone

City, State, Zip Fax

Account #

PLEASE BE SURE TO SUPPLY FAX NUMBERS FOR REFERENCES

Business References (Suppliers, Vendors, Etc.)

1. Company Name Acct No

Address Telephone

City, State Zip Fax

2. Company Name Acct No

Address Telephone

City, State Zip Fax

3. Company Name Acct No

Address Telephone

City, State Zip Fax

Company Type: How would you like to classify your primary business?

DME, Homecare Dealer or Pharmacy
Other
Medical Distributor	Check primary market: Orthopedic PT O & P Podiatry Chiropractic
	Other

Important

Select the product packaging to be used for your orders:

Retail Clamshell (or) Polybag Bulk

Tax I.D. #

*I/We hereby authorize release of any information deemed necessary in connection with a consumer credit report to Swede-O, Inc.

By: Title: Date:

Please return to: Swede-O, Inc., 6459 Ash Street, North Branch, MN 55056

Fax # (651) 674-8425 Phone # (651) 674-8301, ext. 106

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