Please Print
this Form and Fax it to 1 (631) 218-2875 or Mail it to:
American Veterinary Supply Corp.
P.O. Box 9002
155 Knickerbocker Avenue
Bohemia, NY 11716
Customer Account Application (fill out as completely as possible)
_____Corporation _____Partnership _____Proprietorship
Hospital Name_______________________________________________________________
Address ___________________________________________________________________
Phone Number ________________________Fax Number:_____________________________
Years in Business_________________
Veterinarian's Name_________________________________ License & State____________
Home Address________________________________________________________________
Home Phone _____________________________ Social Security #_______________________
Doctor's Signature_____________________________________________________________
Principal's Name_____________________________________________________________
Home Address________________________________________________________________
Social Security #____________________________ License & State______________________
Credit References
Bank Name____________________________ Branch Address_________________________
Account #______________________________ Branch Phone #_________________________
Fax Number____________________________ Date Account Opened ____________________
Trade References
Company Name__________________________________ Account #____________________
Fax Number________________________________ Date Account Opened ________________
Company Name__________________________________ Account #____________________
Fax Number________________________________ Date Account Opened ________________
Company Name__________________________________ Account #____________________
Fax Number________________________________ Date Account Opened _______________
*If controlled substances are to be purchased, DEA Certificate must be supplied.
Terms: N/EOM 15-- 1.99% per month service fee on all past due invoices; COD terms may be substituted as determined necessary by AVSC management. Customer agrees to pay all collection agency fees and commissions related to collection of past due accounts and all court costs including reasonable attorney fees.
Authorized Signature_________________________________________ Date______________
AVSC Representative___________________________________________________________