Application for Credit

All information must be provided with this application. Incomplete applications WILL NOT be processed.
Please have the following required documents available to complete the application: 3 Trade References (if requesting terms), Licensing Information, Initial Purchase Order, Tax Exempt Certificate (if applicable), and W-9.
You will not be able to save this form for completion at a later time – All documents must be attached.
Supported browsers for completing the application: Safari, Internet Explorer & Chrome

Company Info
Billing/Shipping
Click here if Shipping Address is same as Billing Address
Accounts Payable Information
Additional Information
Proprietors, Partners or Officers

Please provide at least 1 proprietor, partner or officer *

Please provide: Name, Title, Phone #, Fax #, Email Address
Customer Identification Information
Use checkboxes to acknowledge the following:
Sales Information
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)

Purchaser is a taxable entity (W-9 form required)
Purchaser is an Exempt organization: please specify below (W-9 and correlating exemption certificate required)
This is a Federal authorized 501(C) 3 Exempt organization (attach photocopy of Federal authorization certificate)
This is a DIRECT PAY PERMIT holder. (attach noted State authorized Direct Pay Permit for exemption)
This is a State authorized EXEMPT organization (attach photocopy of noted State authorization certificate)
This is a Federal GOVERNMENT organization (Army, Navy, Air Force, Marine, VA Hospital – photocopy of Federal authorization certificate not required)
This is a Municipal / Local Exempt organization (attach noted Municipal/Local authorization certificate)
Repairs
All items are purchased for RESALE in the same form (attach photocopy of noted State authorized Resale Certificate or Uniform Multijurisdictional Certificate)
Other valid Exempt Use (Specify and attach corresponding certificate)
Attachments

IMPORTANT: W-9, Tax Exempt Certificate (if applicable), Initial Purchase Order and Prescription Product License 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. If your total document size is greater than 20 MB please compress some of the documents into ZIP files.

Note: The undersigned understands and agrees that if he/she used the tangible personal property other than as stated above or for any purpose which would not exempt the sale under the noted State’s Acts, he/she becomes liable for the tax.
Contact Information

Please list who you wish to be contacted with the results of your application

For questions regarding your application, please contact New Accounts at newaccounts@teleflex.com

Terms and Conditions