Credit Application Form

Customer Account Data

Full Legal Name of Entity * Name line 2 Legal Address *

Form W-9

Please submit a completed W-9 form that matches the information above. PDF/JPG only, file size 15 MB max.

Accounts Payable

Where should we send your invoices?

Bill-to Name * Bill-to Name 2 Bill-to Address *

Payer Information

Who is responsible for paying your invoices?

Payer Address * Same as Bill-to above Different as Bill-to above - please fill in below


Payer Name Payer Name 2 Payer Address

Parent Organization: A parent entity directly or indirectly wholly owns a subsidiary

Parent Organization Name

Affiliated Organization: Is your organization affiliated with any other organization that currently does business with Smith+Nephew? If so, please provide the name of that organization

Affiliated Organization Name

Ship-to Information

Ship-to Address* same as Customer Account Data above different as Customer Account Data above - please fill in below


Address

Facility Information

Type of Ownership * Corporation Sole Proprietorship Partnership-Ownership Percentages Other - please specify below Other Tax Status * Taxable Tax Exempt - Certificate upload required

Certificate needed

A completed certificate must be correctly uploaded, or the account will be set to “Taxable”. PDF/JPG only, file size 15 MB max.

Federal ID# *

Ordering Information

EDI: Electronic submission of purchase orders, receipt of purchase order acknowledgements, advanced shipment notices, and invoices

EDI Capable * Yes No EDI Contact name Invoice Delivery * - S+N offers either EDI (810 transaction) or emailed invoices. By EDI By Email Tracking Email Service * By EDI - 856 transaction By Email By EDI and Email

Pricing Portal: Access to our Pricing Portal. Updated pricing file published monthly to the portal. You will receive an email when the file is available for download. File includes your current contract and/or local pricing, catalog numbers, item descriptions, and selling UoM.

Purchasing Group Affiliation: Indicate ONE purchasing group as your choice for primary affiliation. The purchasing group affiliation will be used by Smith+Nephew to determine eligibility for price discounts and other contract benefits. Applicant must be an active member of the designated purchasing group (Ex Premier, Amerinet, Medassets, HealthTrust, Federal Government).

Sales Details/Forecast

What is the estimated value for monthly sales (in USD)? *

Annual Procedure Volumes

Department

Applicant represents and warrants that the information provided herein is true and correct. Applicant authorizes Smith+Nephew, Inc. to contact any source necessary to determine Applicants credit worthiness. Applicant represents and warrants that this application has been executed by its authorized representative.

Terms & Conditions

I have read and agree to the Terms & Conditions *

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