Credit Application

Vendor/Trade Reference

Street Address:

Account #:

Application Date: 03/21/2023

Please enter all mandatory fields(* marked) information and then click “Submit” to complete your application

Company / Applicant Name:*

Trade Name/DBA:*

Billing Address:

Address 1:*

Address 2:

City:*

State:*

Zip:*

Phone #:* (please use format xxx-xxx-xxxx)

Fax # :* (please use format xxx-xxx-xxxx)

Shipping Address: (Commercial address required)

Same as Billing Address

Address 1:*

Address 2:

City:*

State:*

Zip:*

Phone # :*(please use format xxx-xxx-xxxx)

Fax # :*(please use format xxx-xxx-xxxx)

Additional shipping locations:(Commercial address required)

Business Name:

Address 1:

Address 2:

First Name:

Last Name:

City:

State:

Zip:

Date established:(mm/dd/yyyy)*

Years at location:*

Requested Credit Limit:*

Annual Sales $:*

Please Choose One:*

ProprietorshipPartnershipCorporationOther

Please Choose One:*

Own BusinessRent Your Business?

Please Choose One if you prefer these terms:

Cash With OrderCODCredit Card

Federal Tax ID # :* (please use format xx-xxxxxxx)

Anticipated Monthly Sales $:*

Is Applicant, or any of its Owners or any company in which an Owner has or had a direct or indirect ownership interest within the hearing aid business through any company other than Applicant?*

No
Yes (Please enter the full legal name and address of each company below.)

If any is an Oticon customer, please include the account number. Include all direct and indirect subsidiaries and parent of Applicant.)

Business Name:

First Name:

Last Name:

If Oticon customer, provide name or account #

Street Address:

Suite No:

City:

State:

Zip:

Purchase Order Required:

Number of Invoices Required:

Business email address:

Full legal name of all owner(s), owners of applicant, and any authorized officer or Applicant that signs this application. List home address & zip code for owners

Owner Name:*

Address:*

Social Security #:

Email Address:*

Financial Contact:*

First Name:*

Last Name*

Title:*

Credentials:

Primary Job Function:

Phone #:* (please use format xxx-xxx-xxxx)

Ext

E-mail Address:*

Primary Dispensing Contact:*

First Name:*

Last Name*

Title:*

Credentials:

Primary Job Function:

Phone #:* (please use format xxx-xxx-xxxx)

Ext

E-mail Address:*

Dispensing License #:*

State:*

Has Applicant or any of its affiliates ever filed a voluntary petition in bankruptcy?*

No
Yes (please describe names of parties, when and where it was filed and the circumstances)

Has Applicant or any of its affiliates been the subject of a tax lien, lawsuit, regulatory action, or criminal proceeding within the last 6 years?*

No
Yes (please describe names of parties, when and where it was filed and the circumstances)

Terms

Terms of Payment are 30 days net for service and 60 days net for sales. Past due balances are subject to a finance charge of 1 ½ % monthly or 18% annually. Applicant acknowledges that a monthly finance charge of 1 ½% per month shall be made on all sums due from Applicant that have not been paid when due, subject to any limitations imposed by law. Additional finance charge, computed on the same basis, will be due and payable every 30 days thereafter. Applicant agrees that Oticon’s “Standard Terms and Conditions” as in effect from time to time and set forth on its website will govern transactions with Oticon and are incorporated into this Agreement. Applicant agrees that unless Oticon specifically agrees otherwise in writing, any terms and conditions in any purchase order provided by Applicant that conflict with terms in this Application (including the Standard Terms and Conditions) will be of no force and effect.
Applicant and each Owner hereby (a) authorizes Oticon to obtain credit reports of Applicant(including its Affiliates listed above and consumer credit reports, if applicant and an Owner is an individual), to contact trade references submitted by Applicant in connection with Oticon's initial assessment of creditworthiness, and if Oticon extends credit Applicant, to the administration of such credit:(b)agrees to notify Oticon of any change in the legal business name, status, entity type, or ownership(in excess of 10%) of Applicant and its Affiliates within 5 business days thereafter, and(c) acknowledges and agrees that Oticon is under no obligation to extend credit to Applicant and that any extension and subsequent administration of credit to Applicant by Oticon is in Oticon's sole discretion.
Applicant agrees to pay Oticon's reasonable collection and legal expenses in the event of Applicant's default. Applicant and each Owner further represent that the customer applying for credit has the financial ability and willingness to pay all invoices with established terms. Applicant and each owner hereby waive any right to a trial by jury in any litigation with Oticon. In receiving this Application Oticon also waivers any right to a trial by jury in any such litigation. It is agreed and understood that all necessary collection and legal expenses of 25% plus interest may be charged to the debtor in the event of default or failure to pay for goods sold and delivered.

Signature:*	Title:*	Date

I have read and agree to Oticon’s terms and conditions*

If you have any questions while filling out this form and would like to speak to someone, please call us at 1-800-227-3921. Distribution Guidelines