RAINEY CREDIT APPLICATION

Thank you for choosing Rainey Compression Essentials. Our Primary goal is to offer exemplary products and service at a great value to your practice. In order to offer you exclusive discounted prices, please complete the credit application below. We will process your application within 48 hours and contact you by phone or email with confirmation. Meanwhile, please shop our retail site for your compression garment needs. If you make a purchase before your application is approved, we will factor in your discount before shipping your order.

Legal Name of Company		Date
Legal form of Business	Incorporated Proprietorship Partnership
Billing/Mailing Address		Federal (Tax ID#)
City		Names Of Principles & Titles
State		Names Of Principles & Titles
Zip Code		Names Of Principles & Titles
Phone Number		Fax Number
Person to Contact for Payment
BANK REFERENCES
Name Of Bank		Account Number
Street Address		Name of Contact
City		Phone Number
State		Fax Number
Zip
Name of Bank		Account Number
Street Address		Name of Contact
City		Phone Number
State		Fax Number
Zip
MAJOR TRADE REFERENCES
Name of Company		Phone Number
Mailing Address
City
State
Zip
Name of Company		Phone Number
Mailing Address
City
State
Zip
Name of Company		Phone Number
Mailing Address
City
State
Zip
If you do not want to submit this form via email, you can print it and fax to (404) 373-3027 or call (888) 772-4639
To induce Rainey Compression Essentials to Extend a Line of credit for purchases under credit sales terms of net due upon receipt, as stated on invoices, we authorize Rainey Compression Essentials to contact these references and banks listed above. We also understand that this information will be held in strict confidence and be used solely for the consideration of extension of credit to us.