Attention:   A minimum order of $25.00 (US Orders) and $250 (International Orders) is required for the Internet Orders.
IMPORTANT:  Please make sure your telephone number and/or your e-mail address is correct, since we may need to contact you to confirm the information provided in this application.
**If you are applying for a "Net 30" account, we will need to run a credit check on you to be able to establish such account.
Business Name
Owner or Doctor's Name
BILLING ADDRESS
Address
City, State, Zip
Phone, Fax
E-mail
SHIPPING ADDRESS
"Please Note: We will not ship to P.O. Boxes."
Check here if the Shipping address is the same as Billing address
Contact Name
Shipping Address
City, State, Zip
Phone, Fax
CREDIT INFO
Social Security No.
Tax ID #
Driver's Lic #   St. 
Type of Business:
    Proprietorship    Partnership    Corporation
  Tax Exemption    PC
  Other  
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Important Information:
Due to State and Federal laws: Prior to your first purchase of any controlled substances (IE: Needles, Syringes, Anesthetics, I.V. solutions, Injectables, etc..), please fax and/or mail us a copy of the Doctor's license and DEA number for our records.
State License   Exp. Date 
D.E.A. Number   Exp. Date 
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Bank Information
Bank Name
Branch #
Account #
Account type
Bank Address
City, State, Zip
Phone, Fax
Contact name
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Preferred Method of Payment
    Net 30 Days    Credit Card
  C.O.D.
**If you are requesting a "Net 30" account
(please type in capital "YES"), I authorize Pearson to run a credit check on me, in order to establish a "Net 30" account. I have also read the terms & conditions on the bottom of this page, and agree to it.
**C.O.D. Orders: The limit for company check is $250.00. All orders over $250 must be paid with a cashiers check or money order. (No personal check). C.O.D. orders include a $9.00 charge, plus the shipping charge per shipment."
Credit Card Information:
Credit holder Name
Credit Card #
Card Verification No.
(On the back of your card, find the last 3 digits)
Need help finding your Card Verification Number?
Using American Express?
Credit Card Type
Card Exp. Date
  Checking this box authorizes Pearson Dental to charge this credit card at time of each purchase.
Please press the SUBMIT button only once and wait.
This process my take a few seconds.
Terms and Conditions:  By checking the box below or signing this form, you give Pearson Dental Supply Company permission to request consumer reports from consumer reporting agencies to be used in considering this Application and subsequently for the purpose of any update, renewal, extension of credit, reviewing or collecting on the account. Upon your written request, we will inform you of the name and address of each consumer reporting agency from which we obtain a consumer report relating to you. Proprietorships, Partnerships, or Corporations including professional corporations assume liability for ALL purchases made by any employee, manager, office, doctor, or pharmacist employed when the order was placed. I hereby agree to pay interest on all overdue accounts at the rate of 1.5% monthly, and to pay all costs of collection including reasonable attorney's fees. I hereby certify that the information set forth above, together with all other information submitted in connection with this application, is true and correct.