Agency Profile Form

This form is to be completed by government agencies only.

Agency Information
Agency Name:
Agency Type:

Bill To Address
Address:
City:
State:
Zip Code:

Ship To Address
Shipping same as Billing Address:
Address:
City:
State:
Zip Code:

Misc Information
Tax Exempt:
Tax Exempt #:
Method of Payment:
Medical Director Name:
Medical Director Phone:
Liscense Number:
Expiration Date:

The following information will help us to ensure your transition is as smooth as possible.

Account Ordering Information
Usage Report: Please email or fax a current usage report from your current supplier.
Frequency of Orders:/Week /Month
Preferred Way to Order:
Estimated Annual Volume:

Accounts Payable
Contact:
Phone:
Fax:
Email:
Preferred Way of Contact:


Contact Person
Name:
Phone:
Fax:
Email:
Preferred Way of Contact:
Additional Comments:

Terms and Conditions

  1. The applicant will be responsible for payment of all billings for goods/services. Title to goods covered by all purchases is to remain in the sellerŐs name until all invoices in which goods are billed are paid in full.
  2. All balances after 30 days are subject to a service charge of 1 1/2% per month (18% per year).
  3. Should it be necessary to assign the account to a licensed collection agency or attorney for legal action, all of the subsequent collection charges and legal fees shall be paid by the applicant.
  4. All goods/services are subject to price changes without prior notice to the applicant.
  5. No items will be accepted for a credit return without prior approval and all returns are subject to a restocking fee.
  6. Any discrepancies or claims must be reported within 48 hours of receiving shipment.
  7. Payment on an invoice constitutes an acknowledgment by applicant that the goods provided by J & B Medical are acceptable and fit for the purpose for which they were intended.
  8. In connection with non-payment of an invoice, applicant, in consideration of the extension of credit by J & B Medical, agrees to submit to the personal and exclusive jurisdiction of the 52-1 District Court of the State of Michigan for sums $25,000.00 or less, and the Oakland County Circuit Court of the State of Michigan for sums greater than 25,000.00.
  9. With the exception of non-payment of sums due under any invoice, applicant consents and agrees that all disputes or claims of any nature involving the goods purchased by applicant shall be submitted to binding arbitration with the American Arbitration Association to be held in Southfield, Michigan in accordance with the prevailing commercial arbitration rules of the American Arbitration Association. Applicant agrees that Judgment upon and awarded by the Arbitrator may be entered in the Oakland County Circuit Court, State of Michigan and agrees to submit to the personal and exclusive jurisdiction of the Oakland County Circuit Court, State of Michigan. Applicant agrees that the arbitrator shall award arbitration costs and reasonable attorney fees to the prevailing party.
  10. Any discrepancies or claims regarding pricing must be reported within 48 hours of receipt of invoice.
  11. All goods will be shipped to customer F.O.B. at the point of origin of the shipment.

THE UNDERSIGNED HEREBY AGREES TO ALL TERMS AND CONDITIONS AND ALSO AUTHORIZES AND INSTRUCTS THE RELEASE OF REQUESTED INFORMATION TO J&B MEDICAL SUPPLY CO., INC.

I agree