* = required field

First Name*
Last Name*
Practice Name*
Billing Address*
City*
State*		AL - Alabama AK - Alaska AZ - Arizona AR - Arkansas CA - California CO - Colorado CT - Connecticut DE - Delaware DC - District of Columbia FL - Florida GA - Georgia HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MD - Maryland MA - Massachusetts MI - Michigan MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV - Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VT - Vermont VA - Virginia WA - Washington WV - West Virginia WI - Wisconsin WY - Wyoming
Zip*
Practice Manager
Medical Assistant
Phone Number*
Fax Number*
E-Mail Address*
Business Type*		Corporation Partnership Proprietorship
Tax ID*
Credit Requested
Est. Monthly Volume

Please list the addresses of any satellite offices.

How did you hear about SOLO Laboratories?

Has the company, or any of its principals, ever had a judgement filed against it/them, or been declared insolvent or bankrupt?*

Yes No

If yes, please explain, in detail, whom the judgments were against or who was declared insolvent or bankrupt, including docket numbers and dates.

Company Contact Address Phone Fax E-Mail		Company Contact Address Phone Fax E-Mail
Company Contact Address Phone Fax E-Mail		Company Contact Address Phone Fax E-Mail

Please enter a password that you would like associated with your account.

This application must be signed by owner/principal for credit consideration. The undersigned grants permission to SOLO Laboratories, Inc. to access any credit information available on their company and/or principals in order to establish a credit account. All credit information will be available for review by the company if so requested in writing. All information is held in the strictest confidence. By signing this application, the undersigned acknowledges: that all information supplied is true and correct to the best of your knowledge; that you understand that our terms for payment of invoices are due within THIRTY (30) DAYS from the date of invoice; that you agree to pay 1.5% per month service charge if payment is received more than 30 days from the invoice date; that you are authorized to accept these terms on behalf of the company named herein; that a facsimile of this form and your signature carry the same weight and force as an original signature. Applicant agrees that if accounts are not promptly paid when due, the Applicantis name may be listed in any collection or credit rating file. If applicantis account is referred to collection to an attorney or agency, Applicant will pay reasonable attorneyis fees of FIFTEEN PERCENT (15%) of the sum owed, or FIVE HUNDRED DOLLARS ($500.00), whichever is greater, and costs of collection. Applicant agrees to pay a THIRTY DOLLAR ($30.00) bad check charge for each returned check.

If this application is approved and credit is extended, the Applicant shall be deemed to have agreed to SOLOis terms and conditions, Until such time that SOLO Laboratories, Inc. has approved credit for the Applicant, advance payments may be required. The undersigned, (in his/her individual capacity) as the principal of the company seeking the extension of credit, realizes the importance and value of credit being extended to his/her business, and as a result does personally guarantee payment for any credit extended to the company.

By checking this checkbox, I heareby agree to all of the above statements.