Credit Application

To request an account for your facility to place orders for Optimum Medical products, please complete the following form. A W-9 for your facility must be uploaded to submit your application. If your account is tax exempt, you must upload your Tax Exemption Certificate.

Once your completed form is submitted, we will process within 48 hours and provide an update. If you have any questions, contact us at [email protected].

Requestor

Who is completing this application?

First name * Last name * Email * Phone Title Relationship to facility

Customer account data Full legal name of entity *

Name line 2 DBA

Legal address *

Street Street 2

City State ZIP

Federal ID * NPI Account phone * Fax Company website Main contact email * Ownership type Years in business

Form W-9

Upload a completed W-9 that matches the information above. PDF or JPG, 15 MB max. Required.

W-9 *

Accounts payable

Where should we send your invoices?

Invoice delivery

AP contact name AP email AP phone AP fax

Payer information

Who is responsible for paying your invoices?

Payer address *

Same as bill-to above Different as bill-to — fill in below

Parent organization A parent entity that directly or indirectly wholly owns a subsidiary.

Is your organization affiliated with any other organization that currently does business with Optimum?

No Yes

Ship-to information

Ship-to address *

Same as customer account data above Different — fill in below

Tax status *

Taxable Tax exempt — certificate upload required

Facility Facility name

Facility type (select all that apply)

Ambulatory surgery center Physician office Skilled nursing facility Home health Traveling Physician Group

Facility NPI Phone

Street

City State ZIP

Ordering information Purchasing group affiliation Indicate one primary affiliation used for contract eligibility (for example Premier, Vizient, or HealthTrust). The applicant must be an active member.

Ordering contact Ordering email Ordering phone Shipment tracking

Sales / forecast Optimum Sales Rep When do we expect to receive a first order? *

First order amount Estimated monthly sales ($)

Agreement

I confirm that the information in this application is true and complete, and that I am authorized to submit it. I authorize Optimum Medical LLC to evaluate this application and to contact sources needed to determine credit worthiness. I agree to Optimum Medical’s credit terms as they apply to any account that is opened.

I agree *

Completed by * Title Date