Filter - Med-Dyne

Med-Dyne
Filter Kits
Foam Filters
CPAP Pre-Filters
Inline Bacteria Filters
Bacteria Filters
CPAP Filters
Felt Filters
Proudly Made
in the U.S.A.
Filter Catalog
www.med-dyne.com
1-877-MED-DYNE (633-3963) Phone
[email protected] Email
502-429-6759 Fax
We accept Visa, Mastercard, and American Express
www.med-dyne.com
Med-Dyne Products
5
7
8
12
TABLE OF CONTENTS
Quick Reference Charts.................3-4
Foam Filters...................................5-6
Felt Filters..........................................7
CPAP Pre-Filters (Electrostatic).....8-9
CPAP Pre-Filters (Foam)............10-11
Bacteria Filters.................................11
Filter Kits.........................................12
Inline Bacteria Filters.......................13
Credit Application............................14
Fax/Mail Order Form.......................15
TERMS AND SHIPPING
FOB Louisville, Kentucky. We normally ship UPS ground rate; if requested we will ship Next Day, Two Day, Three
Day Air or by First Class U.S. Mail. Discount pricing is available on volume orders; please phone or fax your request
for a quotation. Our terms are 30 days net from the date of invoice. We also accept Visa, Mastercard and American
Express. Invoices will include sales tax for Kentucky customers, unless a valid seller’s permit number is on file. Our
prices and product lines are subject to change without notice.
TOTAL SATISFACTION GUARANTEE
We promise complete customer satisfaction. If for any reason you are not satisfied with an order, just return the unused
portion (shipping pre-paid) within 30 days of receipt, and we will refund the purchase cost or credit your account.
If you have a particular need which does not appear to be covered by the accessories offered here, please call us; we
may be able to assist you at a substantially reduced cost.
1-877-MED-DYNE (633-3963) Phone
[email protected] Email
502-429-6759 Fax
2
www.med-dyne.com
Quick Reference
Oxygen Concentrator Filters
Part Number
Unit/Manufacturers
FM1204
FM1205
FM1207
FM1209
FM1210
FM1211
FM1212
FM1215
FM1216
FM1217
FM1218
FM1220
FM1225
FM1601
FM1603
FM3631
FM3633
FM3634
FM3637
HealthDyne BX5000
AirSep Forelife Concentrator
AirSep New Life Elite
Invacare Perfecto2
Invacare Mobilaire 513 / IRCs
Invacare Platinum V
Puritan Bennett 590 & 492A Concentrators
Healthdyne Alliance
Oxycon
Healthdyne BX5000, H300, BX300, Alliance & Respironics Millenium
Respironics Millenium
Sports Nebulizer,HDBX5000,Schucco 3000,Aeromax,Invacare Passport, Envoy & Envoy Jr.
Mabis Mini-Comp Nebulizer
All Nidek Concentrators
SeQual Concentrator
MC44-90, PV02D, MC64, MC84,DeVilbiss DeVo 29, & 44 Concentrators
Devilbiss Solaris III
Devilbiss Solaris V 501, 505, 515
Aspen Summit
FT1603
FT3630
FT3638
FT3640
FT3670
FT3680
FT4630
FT4631
FT4632
FT4633
Devilbiss, MC44-90 & PV02
Puritan Bennett 492A & 590
Pulmo-Aid 5610-D, Invacare Stratos, Schucco & Sciotech Suction Machines
Puritan Bennett 590 & 492, Dvo 29 & 44, Inspiron 7500, Solaris III & V
Devilbiss 5650D, Pulmo-Aid, Pulmo Mate
AirSep Elite Concentrators
Puritan Bennett 492A & 590
Puritan Bennett 492A & 590
Puritan Bennett 492A & 590
Puritan Bennett 492A & 590
BF50
BF55
BF85
DeVilbiss29 & 44,PV02D,Puritan-Bennett 492A & 590,HealthdyneBX5000 & Respironics Millennium
Respironics EverFlo Stationary & Oxygen Concentrator & the EverFlo Q
Invacare Platinum V & IRC Series Concntrators
P10
P20
P30
P40
RP458
3655-601
7305D-608
P7178
Invacare Mobilaire, Invacare IRC, Oxycon, MideK Mark 4 & 5, DeVilbiss & BX3000
NewLife, Elite, SeQual, Invacare Platinum V
PB 492A & 590, Healthdye BX5000 & 300, Respironics Millenium, Mallinkrodt 590,590A,492A
Schucco 130 & Invacare IRC 1135
Inspiration Elite Nebulizer (#HS-458), Respironics Inspiration (#929-4)
Pulmo-Aid Compact
DeVilbiss Suction Machine, (Portable unit 7305P-D), (Stationary unit 7305D-D)
In-Line Bacteria Filters
KIT80
KIT85
KIT95
KITMILL
KITEVE
Invacare IRC 5LX, 3LA, 301, 501 Concentrators
Invacare Platinum V Concentrators
Invacare Perfecto2 Concentrators
Respironics Millenium
Respironics EverFlo
3
FOAM FILTERS
FELT FILTERS
BACTERIA FILTERS
INLINE BACTERIA FILTERS
FILTER KITS
1-877-MED-DYNE (633-3963) Phone
[email protected] Email
502-429-6759 Fax
www.med-dyne.com
Quick Reference
CPAP Filters
Unit / Manufacturer
REMstar Pro M Series
REMstar
Sleep Easy
BiPAP S/T
Solo-Ultra Fine
Solo-LX
Aria LX
Virtuoso LX
REMstar LX
Felt Filter
FT4008
FT4010
FT4011
Pollen Foam Filter
RESPIRONICS
FM2008
FM2010
FT4012
FM2012
Aria & Virtuoso Ultra Fine
Duet-LX
REMstar Pro/Plus/Auto/CFlex
Vision BiPAP
FT4015
FT4015, FT4018
FT4019
FT4009
FM2015
FM2018
FM2019
Tranquility
Tranquility Quest
Tranquility MPR
FT4013
FT4014
FT4016
Sullivan
Resmed Sullivan S-6
Resmed Sullivan S-7
Resmed Sullivan S-8
Resmed Auto Set T
Resmed VPAP Adapt SV CPAP
Sandman
GoodKnight
GoodKnight
GoodKnight
GoodKnight
318
418
418 (A/G/P/S)
420 (G/E/S)
Horizon
Horizon LT
RESMED
FT4020
FT4021
FT4022
FT4023
FT4024
FT5015
PURITAN BENNETT
FT5011
FT5013
FT5014
FT6010
FT6012
FT6012
200 Series
Sleepstle 600
FT4031
FT4032
FM2013
FM2014
FM2017
FM5015
FM5012
FM5013
DEVILBISS
Polaris
Polaris LT
Polaris XP
1-877-MED-DYNE (633-3963) Phone
HEALTHDYNE
INVACARE
FM6011
FM6010
FM6012
FM6013
FISHER & PAYKEL
[email protected] Email
502-429-6759 Fax
4
www.med-dyne.com
Foam Filters
All Filter Products Sold in Cases of Twenty
FM1205
FM1204
Description:
Foam Cabinet
Machines Using:
Healthdyne BX5000
Dimensions:
5.5”W x 6”L x 3/8”T
Description:
Foam Cabinet
Machines Using:
AirSep Forelife
concentrator
Dimensions:
4.5”W x 4.5”L x 0.5”T
20 Filters Per Case
20 Filters Per Case
FM1207
FM1210
FM1209
Description:
Foam Cabinet
Machines Using:
AirSep New Life Elite
Dimensions:
3.75”W x 5 3/8”L x 7/8”T
Description:
Foam Cabinet
Machines Using:
Invacare Perfecto2
Dimensions:
3 7/8”W x 7”L x 1/2”T
20 Filters Per Case
20 Filters Per Case
Description:
Foam Cabinet
Machines Using:
Invacare Mobilaire 513/IRCs
Dimensions:
3 3/8”W x 6.75”L x 0.5”T
FM1211
20 Filters Per Case
FM1212
20 Filters Per Case
FM1215
Description:
Foam Cabinet
Machines Using:
Puritan Bennett 590 &
492A concentrators
Dimensions:
4.5”W x 6.75”L x 3/8”T
Description:
Foam Cabinet
Machines Using:
Healthdyne Alliance
Dimensions:
3.75”W x 8”L x 0.25”T
20 Filters Per Case
20 Filters Per Case
FM1216
Description:
Foam Cabinet
Machines Using:
Oxycon
Dimensions:
4”W x 7”L x 3/8”T
FM1217
20 Filters Per Case
5
Description:
Foam Cabinet
Machines Using:
Invacare PlatinumV
concentrator
Dimensions:
2 7/8”W x 9”L x 1/2”T
1-877-MED-DYNE (633-3963) Phone
Description:
Foam Pre Intake
Machines Using:
Healthdyne BX5000, H300,
BX300, Alliance and
Respironics Millennium
Dimensions:
2.5”D x 2.5”T
20 Filters Per Case
[email protected] Email
502-429-6759 Fax
www.med-dyne.com
Foam Filters
All Filter Products Sold in Cases of Twenty
FM1220
FM1218
Description:
Foam Cabinet
Machines Using:
Respironics Millennium
Dimensions:
5.5”W x 6”L x 3/8”T
20 Filters Per Case
FM1225
FM1603
Description:
Foam Cabinet
Machines Using:
Sports Nebulizer, HDBX5000,
Schucco 3000, Aeromax,
Invacare Passport, Envoy,
Envoy Jr.
Dimensions:
5/8”Dia. x 0.5”T
20 Filters Per Case
FM1601
Description:
Foam Cabinet
Machines Using:
Mabis Mini-Comp Nebulizer
Dimensions:
5/8”Dia. x 3/8”T
Description:
Foam Cabinet
Machines Using:
All Nidek Concentrators
Dimensions:
3-5/8 “L x 9 3/4” W x 7/8”T
20 Filters Per Case
10 Filters Per Case
Description:
Foam Cabinet
Machines Using:
SeQual Concentrator
Dimensions:
7 1/2”L x 4 7/8”W x 3/4”T
FM3631
10 Filters Per Case
Description:
Foam Cabinet
Machines Using:
MC44-90, PV02D, MC64,
MC84, DeVilbiss DeVo 29 &
44 concentrators
Dimensions:
3.5”W x 6”L x 0.25”T
20 Filters Per Case
FM3633
FM3634
Description:
Foam Cabinet
Machines Using:
DeVilbiss Solaris III
Dimensions:
3.75”W x 3.75”L x 0.5”T
20 Filters Per Case
FM3637
Description:
Foam Cabinet
Machines Using:
501, 505, 515, DeVilbiss
Solaris V
Dimensions:
5-5/8”W x 3-5/8”L x 5/8”T
20 Filters Per Case
Description:
Foam Block Filter
Machines Using:
Aspen Summit
Dimensions:
2.25”W x 6”L x 2.25”T
20 Filters Per Case
1-877-MED-DYNE (633-3963) Phone
[email protected] Email
502-429-6759 Fax
6
www.med-dyne.com
Felt Filters
All Filter Products Sold in Cases of Twenty
FT1603
FT3630
Description: Felt
Machines Using:
DeVilbiss concentrator,
MC44-90 and PV02
Dimensions:
1.75”W x 2 3/8”L x 0.5”T
Description: Felt
Machines Using:
Puritan Bennett 492A & 590
Dimensions:
2” Dia. x 1/16” x 5/16”T
20 Filters Per Case
20 Filters Per Case
FT3638
FT3640
Description: Felt
Machines Using: PulmoAid 5610-D, Invacare
Stratos, Schucco and
Sciotech suction machine
Dimensions:
0.5” Dia. x 1/8”T
Description: Felt
Machines Using: Puritan
Bennett 590 & 492, DeVo 29 &
44, Inspiron 7500, Solaris III & V
Dimensions:
2” Dia. x 1/16” x 9/16”T
20 Filters Per Case
20 Filters Per Case
FT3670
Description: Felt
Machines Using:
DeVilbiss 5650D,
Pulmo-Aid, Pulmo Mate
Dimensions:
0.75” Dia. x 1”T
FT3680
20 Filters Per Case
20 Filters Per Case
FT4630
Description:
Plastic Pre-Filter Housing
Machines Using:
Puritan Bennett 492A & 590
Dimensions:
2 7/8”T x 2 1/8”W
FT4631
Description: Felt
Pre-Filter Top
Machines Using:
Puritan Bennett 492A & 590
Dimensions:
2”W x 2.75”L x 0.25”T
FT4633
1-877-MED-DYNE (633-3963) Phone
Description:
5 piece kit (pre-filter)
Machines Using:
Puritan Bennett 492A & 590
20 Filter Housing Kits
Per Case
20 Filters Per Case
7
Description: Felt
Pre-Filter Bottom
Machines Using:
Puritan Bennett 492A & 590
Dimensions:
2”W x 2.75”L x 0.25”T
20 Filters Per Case
20 Filter Housings Per Case
FT4632
Description: Felt
Machines Using:
AirSep Elite Concentrators
Dimensions:
1” thick x 1 7/8” diameter
[email protected] Email
502-429-6759 Fax
www.med-dyne.com
CPAP Pre-Filters: (
All Filter Products Sold in Cases of Twenty
FT4008
ELECTROSTATIC FILTRATION MEDIA)
Machines Using:
Respironics REMstar Pro M
Series
Dimensions:
1 3/4”T x 15/16”W
FT4009
20 Pair Per Case
20 Pair Per Case
FT4010
Machines Using:
Respironics REMstar
Dimensions:
5 1/2” x 4 11/16”
FT4011
20 Pair Per Case
FT4012
Machines Using:
Respironics Solo-Ultra Fine,
Solo LX, Aria LX, Virtuoso
LX, REMstar LX, Aria Everest
Dimensions:
3 5/16”T x 2 3/4”W
Machines Using:
Respironics Vision BiPap
Dimensions:
7 1/2”W x 3”T
Machines Using:
Respironics Sleep Easy,
Bipap S/T
Dimensions:
7 3/16”T x 4 7/8”W
20 Pair Per Case
FT4013
Machines Using:
Healthdyne Tranquility
Dimensions:
4 7/8”W x 1 7/8”T
20 Pair Per Case
20 Pair Per Case
FT4014
Machines Using:
Healthdyne Tranquility Quest
Dimensions:
4 1/4”T x 4 1/8”W
FT4015
20 Pair Per Case
FT4016
Machines Using:
Healthdyne Tranquility MPR
Dimensions:
4 3/16”W X 2 1/8”T
20 Pair Per Case
FT4018
20 Pair Per Case
FT4019
Machines Using:
REMstar Pro/Plus/Auto/
CFlex
Dimensions:
3 5/8”W X 1 1/8”T
Machines Using:
Respironics Duet LX,
BiPap 2
Dimensions:
4 13/16”W X 3 1/4”T
20 Pair Per Case
FT4020
20 Pair Per Case
1-877-MED-DYNE (633-3963) Phone
Machines Using:
Respironics Aria & Virtuoso
Ultra Fine
Dimensions:
3 1/8”T x 2”W
[email protected] Email
Machines Using:
Resmed Sullivan S-6
Dimensions:
6”L x .875”W
20 Pair Per Case
502-429-6759 Fax
8
www.med-dyne.com
CPAP Pre-Filters: (
All Filter Products Sold in Cases of Twenty
FT4021
ELECTROSTATIC FILTRATION MEDIA)
FT4022
Machines Using:
Resmed Sullivan S-7
Dimensions:
1 9/16”T x 1 3/8”W
20 Pair Per Case
FT4023
20 Pair Per Case
Machines Using:
ResMed Auto Set T
Dimensions:
3 4/16” W x 4 5/15” L x 3/8” T
FT4024
20 Pair Per Case
FT4031
Machines Using:
Fisher & Paykel 200 Series
Dimensions:
4 15/16”W x 3/4”T
Machines Using:
GoodKnight 418
Dimensions:
2 5/16”W x 1 3/8”T
FT4032
Machines Using:
GoodKnight 420 (G/E/S)
Dimensions:
1 3/4”T x 3/4”W
FT5013
Machines Using:
DeVilbiss Horizon LT/Auto
Ultra Fine
Dimensions:
4 1/8”T x 1 1/4”W
FT5015
1-877-MED-DYNE (633-3963) Phone
Machines Using:
Puritan Bennett Sandman
Dimensions:
1.063” W x 10653” L x 1/16
Radial Corners
20 Pair Per Case
FT6012
20 Pair Per Case
9
Machines Using:
GoodKnight 418 (A/G/P/S)
Dimensions:
5 1/8”T x 3/4”W
20 Pair per Case
20 Pair Per Case
FT6010
Machines Using:
Fisher & Paykel Sleepstle
600
Dimensions:
1” W x 2 7/8” L x 1/2” T
20 Pair Per Case
20 Pair Per Case
FT5014
Machines Using:
ResMed VPAP Adapt SV
CPAP
Dimensions:
2”W x 1”T
20 Pair Per Case
20 Pair Per Case
FT5011
Machines Using:
Resmed Sullivan S-8
Dimensions:
1 7/16”T x 1 3/8”W
Machines Using:
Invacare - Polaris &
Polaris LT
Dimensions:
4 7/8”W x 1 15/16”T
20 Pair Per Case
[email protected] Email
502-429-6759 Fax
www.med-dyne.com
CPAP Pre-Filters: (
All Filter Products Sold in Cases of Twenty
FM2008
FOAM)
Machines Using:
Pro M-Series, Respironics
Remstar
Dimensions:
1-3/4”W x 15/16”L
FM2010
20 Per Case
20 Per Case
FM2012
Machines Using:
Respironics Solo-Foam,
Pollen-Foam Filter
Dimensions:
2.5”W x 3-1/4”L x 5”T
FM2013
Machines Using:
Healthdyne Tranquility Quest
Dimensions:
4.25”W x 4.25 “L x .25”T
FM2015
20 Per Case
FM2017
Machines Using:
Sullivan BiPAP
Dimensions:
6 7/16”W x 11/16”T
FM2018
Machines Using:
REMstar Pro2/Pro/Plus/Auto/
CFlex
Dimensions:
1-5/8”W x 3-5/8”L x 3/8”T
FM5011
Machines Using:
Puritan Bennett - Goodknight
418
Dimensions:
2-3/8”W x 1-3/8”L x 1/2”T
20 Per Case
Machines Using:
Puritan Bennett - CPAP Filter
for Goodnight 318
Dimensions:
6-1/8”W x 1”L x 1/4”T
FM5013
20 Per Case
1-877-MED-DYNE (633-3963) Phone
Machines Using:
Duet LX
Dimensions:
2.375”W x 4.75”L x .375”T
20 Per Case
20 Per Case
FM5012
Machines Using:
Respironics Aria & Virtuoso
Pollen Filter
Dimensions:
2.25”W x 3.5 “L x .25”T
20 Per Case
20 Per Case
FM2019
Machines Using:
Healthdyne Tranquility
Dimensions:
5 1/4”W x 2”T Base 1” Top
20 Per Case
20 Per Case
FM2014
Machines Using:
Respironics Remstar
Dimensions:
3/8”T x 3-3/8”Oval
[email protected] Email
Machines Using:
Puritan Bennett 418G
Dimensions:
5 1/8”W x 3/4”T
20 Per Case
502-429-6759 Fax
10
www.med-dyne.com
CPAP Pre-Filters: (
All Filter Products Sold in Cases of Twenty
FM5014
FOAM)
Machines Using:
Puritan Bennett -GoodKnight 420 S/G/E
Dimensions:
1-7/8”W x 7/8”L x 1/4”T
FM5015
20 Per Case
20 Per Case
FM6010
Machines Using:
Devilbiss Horizon LT / Auto
Dimensions:
4”W x 1 3/16”L x 1/4”T
FM6011
20 Per Case
FM6012
Machines Using:
Invacare Polaris
Dimensions:
5”W x 2”T
Machines Using:
Puritan Bennett Sandman
Dimensions:
1.063”W x 1.625” L x 12” T
Machines Using:
Devilbiss Horizon
Dimensions:
4”W x 1 1/8”T
20 Per Case
FM6013
20 Per Case
Machines Using:
Invacare Polaris XP
Dimensions:
2-1/4”W x 1”L x 3/8”T
20 Per Case
Bacteria Filters
BF50
Description:
Intake, Compressor Filter
Machines Using: DeVilbiss
29, 44, PV02D, PuritanBennett 492A & 590
Healthdyne BX5000, and
Respironics Millennium
Concentrator Filters
BF55
20 Per Case
20 Per case
BF85
Description:
Intake Filter
Machines Using:
Respironics EverFlo
Stationary and Oxygen
Concentrator and the
EverFlo Q
Description:
Intake Filter
Machines Using:
Invacare PlatinumV and IRC
Series Concentrators
20 Per Case
11
1-877-MED-DYNE (633-3963) Phone
[email protected] Email
502-429-6759 Fax
www.med-dyne.com
Filter Kits
All Filter Kits Sold in Cases of Twenty
KIT85
KIT80
Description: Four piece filter
kit for the Invacare IRC 5LX,
3LA, 301, 501 conc.
Kit Contains:
(1) P10
(1) BF85
(2) FM1210
Description: Four piece filter
kit for the Invacare Platinum
V conc.
Kit Contains:
(1) P20
(1) BF85
(2) FM1211
20 Kits Per Case
20 Kits Per Case
KITMILL
KIT95
Description: Four piece filter
kit for the Invacare Perfecto2
conc.
Kit Contains:
(1) P20
(1) BF85
(2) FM1209
Description: Four piece filter
kit for Respironics Millennium
Kit Contains:
(1) P30
(1) BF50
(1) FM1217
(1) FM1218
20 Kits Per Case
20 Kits Per Case
KITEVE
Description: 2 Piece Filter
Kit for the Respironics
EverFlo filter kit
Kit Contains:
(1) P30
(1) BF55
20 Kits Per Case
­­
Med-Dyne
is a company that is an industrial leader in infant apnea, ECG and filter supply. Med-Dyne
prides itself on its long history in the medical industry. The quality of production and customer
service has helped us maintain an excellent reputation with customers and will allow us the opportunity
for future growth.
Check out our full line of products online at www.med-dyne.com, or contact us to see how we can help
you. Call us toll-free 1-877-MED-DYNE (633-3963) or send us an email at [email protected] and
our customer service team will offer you expert advice on the latest medical supplies and equipment.
1-877-MED-DYNE (633-3963) Phone
[email protected] Email
502-429-6759 Fax
12
www.med-dyne.com
Inline Bacteria Filters
All Inline Bateria Filters Sold in Cases of Five
P10
P20
Description:
Final Bacteria Disc Filter
1/4” - 3/8”
Stepped barb on each end
Compatible With:
Newlife, Elite, SeQual,
Invacare Platinum V
Description:
Final Bacteria Disc Filter
5/16”
Straight barb on each side
Compatible With:
Invacare Mobilaire, Invacare
IRC, Oxycon, NideK Mark 4 &
5, DeVilbiss, and BX3000
5 Filters Per Case
5 Filters Per Case
P30
P40
RP458
Description: Final Bacteria
Disc Filter 3/16” - 1/4”
Stepped barb on each end
Compatible With: PB492A,
Healthdyne BX5000, PB590,
H300, Respironics Millennium,
Mallinkrodt 590, 590a, 492a
Description:
Suction Machine Bacteria
Filter 1/4” - 3/8”
Stepped barb, screw mount
Compatible With:
Schuco 130 & Invacare IRC
1135
5 Filters Per Case
5 Filters Per Case
Description:
Intake Filter
Compatible With:
Inspiration Elite Nebulizer
(part # HS-458)
Respironics Inspiration
(part # 929-4)
3655-601
Description:
Intake Filter
Compatible With:
Pulmo - Aid Compact
5 Filters Per Case
5 Filters Per Case
7305D-608
Description:
Intake Filter
Compatible With:
DeVilbiss Suction Machine
Portable Unit: 7305P-D
Stationary Unit: 7305D-D
P7178
Description:
Intake Filter
Compatible With:
In-line Bacteria Filters
5 Filters Per Case
5 Filters Per Case
13
1-877-MED-DYNE (633-3963) Phone
[email protected] Email
502-429-6759 Fax
www.med-dyne.com
Credit Application
Med-Dyne
I, (we) submit the following information in applying for an open account:
Business Name ______________________________________
Type of Business ______________________________________
Address ____________________________________________
Shipping Address ______________________________________
City __________________ State ________ Zip ____________
City ____________________ State ________ Zip __________
Phone Number (
Phone Number (
Fax Number (
) ________________________________
) ________________________________
Fax Number (
) ________________________________
) ________________________________
Accounts Payable Contact ______________________________________________________________________________________
COMPLETE APPLICABLE SECTION:
Individual
Partnership
Corporation
Subsidiary of
Owner’s. Officer’s Director’s or Partner’s Names:
1. __________________________ Address ____________________
City ____________________ State ____ Zip __________
2. __________________________ Address ____________________
City ____________________ State ____ Zip __________
Year Incorporated ______________ State ______________________
Year in Business __________________________________
Owner’s Social Security __________________________________
PERSONAL GUARANTEE: In consideration for credit extended, the undersigned individual contracts and guarantees to faithful payment, when due, of all accounts of the
company seeking credit under this application. The undersigned guarantor expressly waives all notice of acceptance of this guarantee, notice of extension of credit, presenting
of demand for payment and any notice of default by the company seeking credit and all other notices the guarantor might be entitled to.
Name ______________________________________________
Date ______________
Business Name ____________________________________________
Checking Account # ______________________________
Address __________________________________________________
Savings Account # ______________________________
City ________________________________State______ Zip ____________ Phone Number (
TRADE (1) ____________________________________________ Acct. #
) __________________________
______________________________________________
Address ____________________________ City ______________ State______ Zip __________ Tel. # (
TRADE (2) ____________________________________________ Acct. #
Address ____________________________ City ______________ State______ Zip __________ Tel. # (
TRADE (3) ____________________________________________ Acct. #
) ________________
______________________________________________
) ________________
______________________________________________
Address ____________________________ City ______________ State______ Zip __________ Tel. # (
) ________________
TERMS: Credit Terms are 30 Days from date of invoice. Outstanding balances are subject to 1.5% per month interest. The undersigned authorizes and releases all banks,
persons and companies listed on this application. The undersigned agrees to pay all collection costs and legal fees incurred to collect delinquent balances.
I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND AGREE TO THE ABOVE SHOWN.
SIGNATURE OF OWNER/PARTNER OR OFFICER
DATE
AUTHORIZED SIGNATURE OTHER THAN ABOVE
DATE
FIRM NAME: ________________________________________________________________________________________________________________________________
I HEREBY CERTIFY, That I hold valid seller’s permit Number: ________________________________________________________________________________________
issued pursuant to the Sales and Use Tax Law; that I am engaged in the business of selling: ________________________________________________________________
THAT THE TANGIBLE PERSONAL PROPERTY DESCRIBED HEREIN WHICH I SHALL PURCHASE WILL BE RESOLD BY ME IN THE FORM OF TANGIBLE PERSONAL PROPERTY; PROVIDED,
HOWEVER THAT IN THE EVENT ANY SUCH PROPERTY IS USED FOR ANY PURPOSE OTHER THAN RETENTION, DEMONSTRATION OR DISPLAY WHILE HOLDING IT FOR SALE IN THE
REGULAR COURSE OF BUSINESS, IT IS UNDERSTOOD THAT I AM REQUIRED BY SALES AND USE TAX LAW TO REPORT AND PAY FOR THE TAX, MEASURED BY THE PURCHASE PRICE OF
SUCH PROPERTY.
Description of property purchased ________________________________________________________________________________
Date ______________ 20 ____ Purchaser: ________________________________________________________________________
By and Title:
____________________________________________________________ Telephone # (
) __________________
Address ______________________________________________ City ______________ State ______ Zip ____________________
1-877-MED-DYNE (633-3963) Phone
[email protected] Email
502-429-6759 Fax
14
www.med-dyne.com
Fax/Mail Order Form
15
1-877-MED-DYNE (633-3963) Phone
[email protected] Email
502-429-6759 Fax