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Stat Medical Inc.
CREDIT APPLICATION

PLEASE NOTE THAT CREDIT WILL NOT BE ISSUED TO INCOMPLETE APPLICATIONS

* Company Name
* Address
Address
Country Province/State
City Postal/Zip Code
* Company Phone Number
- -
* Company Fax Number
- -
* Accounts Payable Contact
* Company Contact Email
Years in Business
* Business Type
* Have you purchased from Stat Medical Inc previously?
* Has your company ever declared bankruptcy?

BANKING

* Name Of Bank
* Bank Address
Address
Country Province/State
City Postal/Zip Code
* Bank Contact Name
* Bank Contact Email
* Bank Phone Number
- -
Bank Fax:
- -
* Credit Amount Requested

TRADE REFERENCES

* TRADE REFERENCE NAME #1:
* TR#1 Phone Number
- -
TR#1 Fax Number
- -
* A/P Contact Name
* A/P Contact Email

Trade Reference #2

* TRADE REFERENCE NAME #2:
* TR#2 Phone Number
- -
TR#2 Fax Number
- -
* A/P Contact Name
* A/P Contact Email

Trade Reference #3

* TRADE REFERENCE NAME #3:
* TR#3 Phone Number
- -
TR#3 Fax Number
- -
* A/P Contact Name
* A/P Contact Email

The information on this form hereof is provided for the purpose of obtaining credit and is warranted to be true,
correct and complete. I hereby authorize Stat Medical Inc to investigate the references listed as relating to your
credit request.


Applicant hereby certifies that the information furnished under this Application and any other financial statement
furnished in connection herewith, is true and correct and that this information is being furnished to Seller to extend
credit to Applicant, and understands that Seller intends to rely upon such information. Applicant understands and
agrees to be bound by the terms shown on our website at https://www.statmedicalcanada.com/tc, and all
invoices and other documents furnished by Seller from time to time, all of which are incorporated herein by
reference, and to advise Seller of any material change in the information provided herein, including but not
limited to change of ownership, address or telephone. Applicant understands that Seller will retain this
Application whether or not it is approved. Applicant hereby authorizes Seller to check Applicant’s credit history
and trade and bank references for customary credit information, to confirm the information contained on the
Application including, but not limited to sending a copy hereof to the trade and bank references, and to release
information to other creditors regarding Applicant’s credit experience with Seller.

APPLICANT UNDERSTANDS THAT THE DETAILS CONTAINED IN THIS FORM ARE INTENDED FOR THE PURPOSES OF ESTABLISHING CREDIT TERMS WITH STAT MEDICAL INC

* I have the authority to submit this request on behalf of my company
* Submitters Name
Submitters Title
Submission date
/ /