New Account Application | US

Account

Account Type *

* Please Note: Requires minimum initial purchase order of $500.

Company Info

Company Name *

DBA/AKA (Doing Business As/Also Known As)

Telephone *

Ext

Fax

DUNS# (Dun & Bradstreet Number)

EIN# (Employer Identification Number; found on W-9 form) *

Billing/Shipping

Billing Address *

City *

State *

ZIP *

Click here if Shipping Address is same as Billing Address

Shipping Address *

City *

State *

ZIP *

Accounts Payable Information

A/P Contact (First/Last) *

A/P Email *

A/P Phone *

A/P Fax

Please check here if you prefer to receive your invoices electronically.

Please check here if you prefer to receive your statements electronically.

Customer Identification Information

Have you ever had an account with any Teleflex division? * Yes No

Explain other account *

Are you part of an IDN Health System or Physician Group? *
Yes No

List Specific IDN/Physician Group *

GPO *(If affiliated with a group purchasing organization, please note)

GPO Other *

License Type * (Click dropdown for a list of options)

Other License Type *

License Number *

License Expiration Date *

Global Location Number GLN If information is not available please type N/A

Type of Business *

Other *

Use checkboxes to acknowledge the following:

The above named firm hereby makes application for credit and provides the information contained herein for the purpose of inducing Teleflex LLC to make periodic sales of goods and equipment to it on credit. In consideration thereof, it is agreed and understood that (1) the undersigned is an authorized agent of the applicant and is duly empowered to enter into and make a binding agreement on its behalf and (2) applicant authorizes its creditors, banks and financial institutions to release credit, banking and financial data to Teleflex LLC. Further it is agreed that North Carolina courts shall have exclusive jurisdiction to litigate any dispute between applicant and Teleflex LLC and any and all litigation shall be instituted and litigated in the courts of Wake County, State of North Carolina. Applicant waives any right to a change of venue or change of jurisdiction and hereby submits to and acknowledges the jurisdiction of any such court, state or federal, as provided herein. Terms are from invoice date. Standard Terms are NET 30 and will be based On Approved Credit.

Trade References

PLEASE NOTE:
No personal references will be accepted. Cardinal, Cardinal Health, McKesson, Medline, Medtronic, and Owens & Minor will not provide information to Teleflex so please refrain from using them as a reference on the application.

Government entities or municipalities check here.
To attach a list of references in the "Other Documentation" section below check here.

Company Name *

Account # *

City *

State *

Phone *

Email *

Company Name *

Account # *

City *

State *

Phone *

Email *

Company Name *

Account # *

City *

State *

Phone *

Email *

Sales Information

Sales Rep Contact Information (if known)

Sales Rep Contact Email (if known)

Estimated Annual Purchases *

Sales Tax
All sales are considered Taxable, unless a Resale or Tax Exemption Certificate is completed, signed and returned for each Ship to Location. To ensure that none of your orders ship as taxable, please return the completed Resale and Tax Exemption Certificate with your completed Credit Application.

Purchaser Sales/Use Tax Declaration

Purchaser hereby certifies to the seller that: (please check appropriate box below and provide copy of W-9 in all cases and corresponding exemption certificate, if required)

Yes No

Purchaser is a taxable entity (W-9 form required)

Yes No

Purchaser is an Exempt organization: please specify below (W-9 and correlating exemption certificate required)

Attachments

IMPORTANT: W-9, Tax Exempt Certificate (if applicable), Initial Purchase Order and License Information are all required documents. Teleflex products contain an RX label and as a result Teleflex now requires all customers to produce a valid state and/or federal license or registration that authorizes receipt of prescription devices. Missing documents will cause delays in account setup.

Forms with more than 20 MB of attachments may have trouble e-mailing successfully.

License Information *

W-9 or Tax Exempt Certificate *

Initial Purchase Order * If you do not have a purchase order, you may attach a quote or a letter that includes a list of products you wish to purchase.