ICP Medical Healthcare Supplies Infection Control and Safety Products


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Request for Corporate Account
To request an open terms corporate account, please fill or confirm the information below and click the "Submit Request Now" button.

Section 1
Billing Information
Company Name:
Address:
City:
State:
Zip Code:
Accounts Payable Contact:
A/P Phone #:
A/P Fax #:
A/P E-mail:

Section 2
Please Indicate Type of Business:	Individual Partnership Corporation
Name of Owner/Owners:
Owners Address:
Federal Tax ID #:
Length of Time in Business:

Bank Reference
Bank Name:
Phone #:
City:
State:
Zip Code:
Checking Account #:
Saving Account #:

Credit References
1. Name:
Phone #:
City:
State:
Zip Code:
2. Name:
Phone #:
City:
State:
Zip Code:
3. Name:
Phone #:
City:
State:
Zip Code:

OR download our Credit Application PDF, fill it out, and fax it to 314-429-8626, attn: Lisa.