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D.B.A.: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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State Incorporated In: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Mailing Address: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Federal Tax I.D.: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Medicare PTAN Number: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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NPI Number: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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State Tax Exempt for Resale Number: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If YES, VGM Member Number: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please upload your Sales Tax Exemption Resale Certificate: (Supported file types are: .PDF and .JPG) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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PRINCIPALS (All Must Be Listed):
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Name: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Title: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Title: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Type of Business: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Years in Business: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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ACCOUNTS PAYABLE & WEBSITE ACCESS:
Accounts Payable Contact Name: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Title: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Primary Contact for Application & Credit Questions: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Primary Contact to Receive Electronic Invoices: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Secondary Contact to Receive Electronic Invoices: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Primary Admin for your GEMCO Medical Online Shopping Account: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Primary Admin's Email: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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PREFERRED PAYMENT METHOD:
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Line of Credit Request (Must Complete Following Page): {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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PERSONAL GUARANTY:
PERSONAL GUARANTY: All individuals and all partners in a partnership must sign personal guarantee. If corporation and incorporated under two years, personal guarantee must be signed by a corporate officer. In consideration of credit granted by GEMCO Medical, the undersigned personally guarantees any and all attorney’s fees and collection costs. In the event payment is demanded by GEMCO Medical, the undersigned agrees to make payment within 30 days.
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I understand that checking this box constitutes the above as a legal signature. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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BANK INFORMATION:
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Checking Account #: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Primary Bank Address: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Primary Bank Contact: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Fax : {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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TRADE REFERENCES (for Line of Credit Request):
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Account #: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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# of Years: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Trade Reference Name #2: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Trade Reference Name #3: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Trade Reference Name #3: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Account #: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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LICENSE AGREEMENT:
During the term of this Agreement, Customer will obtain and maintain from the appropriate federal, state, and local agencies, current valid and restricted licenses, permits, and/or certifications that are required to lawfully furnish products purchased from GEMCO Medical.
Customer agrees to provide evidence of licenses, permits, and/or certifications as required or the distribution of prescription legend devices. Please attach copies of all license(s) to this application using the upload button below:
License(s):
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ACCOUNT AGREEMENT & TERMS OF SALE:
The undersigned hereby applies to GEM Edwards (d.b.a. GEMCO Medical) for credit. It is understood and agreed that the undersigned specifically consents to GEMCO Medical investigating the applicant’s credit history, which may include the use of “Third Party” Commercial and/or Consumer Credit Reports for the purpose of extending credit.
Prices are subject to change without notice. The most recent price list supersedes previously published price lists. All pricing and/or special considerations are dependent on Customer’s account being current within payment terms.
GEMCO Medical’s terms are Net 30 days from the invoice date. A finance charge of 2% will be charged monthly on outstanding balances, which are 30 days past the invoice date. Orders will not be shipped on delinquent accounts. GEMCO Medical reserves the right to terminate open account credit at any time. If default of payment occurs, the customer agrees to pay any and all attorney’s fees and collections costs, up to and including asset seizure. The validity, effect, interpretation and performance of this agreement will be governed by the laws of the state of Ohio. The Court of Common Pleas in Summit County, Ohio shall have exclusive jurisdiction over any suits, causes of action, or any other legal disputes between the parties, and/or their successors, which may arise under the terms of this Agreement and Guaranty. The undersigned Owner (and Guarantor) hereby expressly consent to said Court’s jurisdiction.
Unless specified otherwise, all orders will be shipped by the most cost-effective method available. Shipping charges and a handling fee will be added to your invoice. Shipments outside the continental U.S. will be billed accordingly. Customer is responsible for any additional shipping charges due to Customer supplying an incorrect shipping address.
Notification of shortages and/or damages must be made within three (3) business days of receipt. All returns for credit require a Return Merchandise Authorization number (RMA #) from the GEMCO Medical Returns Department. This number is valid for 30 days. A copy of the RMA must accompany the return for proper credit to be issued. Shipping charges on all returned goods will be incurred by the customer. All goods will be inspected prior to issuing a credit. Returns on stocked items due to errors in ordering or overstocks, when returned in resalable condition, will receive:
- Full credit for returns within 30 days
- DME products reserve the right to charge 25% for returns at any time
NO RETURNS ON:
- Special Order items
- Continuous Glucose Monitor Sensors (CGMS)
- Insulin Pumps, Insulin Management Systems, Continuous Glucose Monitor (CGM) Transmitters and Continuous Glucose Monitor (CGM) Receivers that have been opened or are not in resalable condition
Defective products require a RMA # from our Returns Department. A detailed description of the defect must be included with the return. Shipping must be prepaid by the customer, no COD accepted. Replacement/credit of defective product will be made after inspection and agreement by GEMCO Medical and the manufacturer.
Customer shall notify GEMCO Medical in writing within five (5) business days of any prospective or pending change in Customer’s ownership interest in the Company, or any change in the relationship of the signatories herein to the Company. If GEMCO Medical is not notified, current owner(s) shall be responsible for all balances due GEMCO Medical. GEMCO Medical reserves the right to require a signed promise to pay agreement by new owner(s).
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