New Account/Credit Application - Performance Business Consultants

Medical & Surgical
Equipment Sales & Service

(888) 285-6612

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End of the Year Sale! 25% OFF Select Items, Click For Huge Savings!

End of the Year Sale!
25% OFF
Select Items
Click For Huge Savings!!!

(888) 285-6612

Medical & Surgical Equipment Sales & Service

(888) 285-6612

Performance Business Consultants, LLC

New Account/Credit Application

First Name

Last Name

Title

Email

Website

Name of Business

Tax ID Number

Address

City

State

Zip

Phone

Industry

Date Founded

Company Type

If Division/Subsidiary, Name of Parent Company:

Parent Company

Parent Date Founded

Name of Company Principal Responsible for Business Transactions

Principal Title

Principal Email

Parent Website

Parent Address

Parent City

Parent State

Parent Zip

Parent Phone

Bank Name

Checking Account Number

Bank Address

Bank City

Bank State

Bank Zip

Bank Phone

Reference 1

Reference 1 Company Name

Reference 1 Contact Name

Reference 1 Address

Reference 1 City

Reference 1 State

Reference 1 Zip

Reference 1 Phone

Reference 1 Open Date

Reference 1 Credit Limit

Reference 1 Current Balance

Reference 2

Reference 2 Company Name

Reference 2 Contact Name

Reference 2 Address

Reference 2 City

Reference 2 State

Reference 2 Zip

Reference 2 Phone

Reference 2 Open Date

Reference 2 Credit Limit

Reference 2 Current Balance

Reference 2

Reference 3 Company Name

Reference 3 Contact Name

Reference 3 Address

Reference 3 City

Reference 3 State

Reference 3 Zip

Reference 3 Phone

Reference 3 Open Date

Reference 3 Credit Limit

Reference 3 Current Balance

Acceptance

I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the legitimacy of the company and/or the amount and conditions of the credit to be extended. Furthermore, I hereby authorize the financial institutions listed in this credit application to release necessary information to the company for which a new account or credit is being applied for in order to verify the information contained herein.

Acceptance Date

PBC Solutions
1084 N El Camino Real Ste B
Encinitas, CA 92024

Monday–Friday: 8am to 5pm PST
Saturday/Sunday: Closed

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