Credit Application

Business Type: *

Estimated Annual Purchases: *

Initial Order Date: *

Billing Address

Business Name (DBA): *

Legal Name: *

Street Address: *

City: *

Country: *

State:

ZIP/Postal Code: *

Email Address: *

Please enter the email address where we should send confirmation of this application.

Phone: *

Fax: *

Website:

Shipping Address

Shipping address is same as billing address:

Shipping address is same as billing address

Business Name (DBA): *

Street Address: *

City: *

Country: *

State:

ZIP/Postal Code: *

Phone: *

Fax:

UPS/FedEx #:

Principals in the Business

Name:

Title:

Phone:

Name:

Title:

Phone:

References

You may either upload documentation, or you may complete the forms below.

You may upload documentation:

You may upload a second document:

Bank References

Business Name:

Contact Name:

Address:

Phone:

Trade References

Business Name:

Contact Name:

Address:

Phone:

Business Name:

Contact Name:

Address:

Phone:

Business Name:

Contact Name:

Address:

Phone:

Is Your Business Tax Exempt: *

Yes

Important: If your business is tax exempt, you must fax or upload a tax exempt certificate to Cochlear at (303) 524-6781 with your credit application. Tax law requires Cochlear to collect and remit tax on all taxable sales until this documentation is on file.

You may also upload the certificate:

Accounts Payable Contact

Last Name: *

First Name: *

Phone: *

Email:

Fax:

Purchasing Contact

Last Name:

First Name:

Phone:

Email:

Fax:

Disclaimer

I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended by Cochlear Americas.

I acknowledge the above disclaimer: *

Yes

Name: *

Title: *

Form type:

Business

Credit Application

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