CUSTOMER CREDIT APPLICATION

QuadMed, Inc.

P.O. Box 550773, Jacksonville, FL 32255-0773
TEL : 800-933-7334 FAX: 877-367-7759 SALES@QUADMED.COM WWW.QUADMED.COM

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  • BUSINESS CONTACT INFORMATION

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  • BUSINESS AND CREDIT INFORMATION

  • List Account Number(s) Below

  • BUSINESS/TRADE REFERENCES – MUST HAVE RECENT ACTIVITY / WITHIN PAST 12 MONTHS

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  • AGREEMENT

  • 1. All invoices are to be paid 30 days from the date of the invoice

    2. Claims arising from invoices must be made within ten (10) working days.

    3. Refer to our Catalog’s General Information page for other pertinent information regarding Terms.

    4. By submitting this application, I authorize QuadMed, Inc. to make inquiries into my banking and business/trade references.

  • SIGNATURES

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