Business Credit Application SCA

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Business Credit Application

Payment Information

Credit card payments - Only VISA & Mastercard accepted

EFT - Net 30

Payment Terms*

Credit Card EFT

Credit Card Contact Name*

First Name

Last Name

Phone Number*

By providing credit card information I am allowing Sigvaris to charge outstanding amounts as per payment terms.

When an order is placed, there will be a pre-authorization pending amount that will be temporarily held on the credit card for 48/72 hours to cover the estimated cost of the order & freight.

The credit card will only be charged the amount of the invoice when the products are shipped.

Please contact canada.ar@sigvaris.com for further information.

I certify that the above information is true to the best of my knowledge. If credit is granted we agree to abide by the payment terms issued. It is also understood that business relationships resulting from this application will be enforced in accordance with the laws of the province of Quebec.

Signature*

[clear]

Use your mouse or finger to draw your signature above

Signer Name*

First Name

Last Name

Signer Title*

Signature Date*

Dealer Portal Registration

Dealer Portal Online Ordering is a quick and easy way to place your orders online, instantly. There are no forms to complete or phone calls to place. Online ordering validates all SKU’s and verifies your order before you submit it. Once submitted a confirmation email with your order number and details will be sent to you. Please complete the registration process by providing us with current, complete and accurate information.

Would you like to delete all Dealer Portal accounts that were active prior to the change of ownership?*

Yes No N/A

Name of Designated Dealer Portal User*

First Name

Last Name

Designated Dealer Portal User Email Address*

Customer Care Redirect

Completed by CCR*

First Name

Last Name

Region*

Central / West Central / East Quebec Alternative Approval (OOO)

Territory*

Alternate Approver Email*

Original Syspro ID

Status of the Original Syspro Account

Regional Approval

Regional Manager*

First Name

Last Name

Date*

Approved?*

Yes No

Original Syspro ID

Status of the Original Syspro Account

Customer Class*

Channel*

Associated Territory*

Territory Manager Email*

Membership #

Veeva URL*

Order Documentation

No File Chosen

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Authorization Email

No File Chosen

File uploads may not work on some mobile devices.

Customer Care - Account Creation

Account Opened By*

First Name

Last Name

Date of Account Creation*

Syspro ID*

New Syspro ID

Buying Group

Separate by commas if multiple

Customer's Preferred Payment Method; Credit Card

Customer's Preferred Payment Method; EFT

Terms by Customer Class

06, 24 - Terms 15

09 - Terms 60

19 - Terms 14

22 - Terms N3

28 - Terms CC

52, 54 - Terms 35

Everything Except the Class' Above - Terms 10 or CT Depending Customers Preference

Comments

Signature*

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Customer Care - DP Creation & Order Entry

Section Completed By?*

First Name

Last Name

Completed Date*

Created DP Account?*

Yes No

Syspro ID

Order #

Comments

Signature*

[clear]

Use your mouse or finger to draw your signature above

Finance Team Approval

Finance User*

First Name

Last Name

Date*

Approved?*

Yes No

Customer's Preferred Payment Method; Credit Card, update Syspro account to CT

Customer's Preferred Payment Method; EFT

Terms by Customer Class

06, 24 - Terms 15

09 - Terms 60

19 - Terms 14

22 - Terms N3

28 - Terms CC

52, 54 - Terms 35

Everything Except the Class' Above - Terms 10 or CT Depending Customers Preference

Payment Terms*

Signature*

[clear]

Use your mouse or finger to draw your signature above

Company Information

Payment Information

Dealer Portal Registration

Customer Care Redirect

Regional Approval

Customer Care - Account Creation

Customer Care - DP Creation & Order Entry

Finance Team Approval