New Account Application | Canada

Account

Account Type *

Company Info

Company Name *

DBA/AKA (Doing Business As/Also Known As)

Telephone *

Ext

Fax

Billing/Shipping

Billing Address *

City *

Province *

Postal Code *

Click here if Shipping Address is same as Billing Address

Shipping Address *

City *

Province *

Postal Code *

Accounts Payable Information

A/P Contact (First/Last) *

A/P Email *

A/P Phone *

A/P Fax

Invoice and Statement Information

Email for Invoices *

Email for Statements *

Customer Identification Information

Have you ever had an account with any Teleflex division? * Yes No

Explain other account *

Are you part of IDN Health System? * Yes No

List Specific IDN *

GPO *(If affiliated with a group purchasing organization, please note)

GPO Other *

Global Location Number GLN If information is not available please type N/A

Type of Business *

Other *

Use checkbox to acknowledge the following:

The above named firm hereby makes application for credit and provides the information contained herein for the purpose of inducing Teleflex Medical Canada Inc. to make periodic sales of goods and equipment to it on credit. In consideration thereof, it is agreed and understood that (1) the undersigned is an authorized agent of the applicant and is duly empowered to enter into and make a binding agreement on its behalf and (2) applicant authorizes its creditors, banks and financial institutions to release credit, banking and financial data to Teleflex Medical Canada Inc. Further it is agreed that Ontario courts shall have exclusive jurisdiction to litigate any dispute between applicant and Teleflex Medical Canada Inc. and any and all litigation shall be instituted and litigated in the courts sitting in the Province of Ontario. Applicant waives any right to a change of venue or change of jurisdiction and hereby submits to and acknowledges the jurisdiction of any such court, as provided herein. Terms are from invoice date. Standard Terms are NET 30 and will be based On Approved Credit.

Sales Information

Sales Rep Contact Information (if known)

Sales Rep Contact Email (if known)