PMA - Midway Registration

Terms & Conditions:

I agree that I am liable for any written or verbal orders that are invoiced upon receipt. I will inspect orders upon delivery and contact Midway Dental Supply to report any discrepancies, missing items, and/or damaged items within 7 days of receipt. In the event any balance is not paid within the terms stated and any suit or action is brought to enforce or interpret any of the terms of this Agreement, I agree to pay all actual costs of collection, including actual attorney’s fees and court costs and interest charged at the annual rate of 18% whether or not litigation is commenced or prosecuted to final judgment. In the event I sell, transfer or change the ownership or legal structure of our business, I agree to provide written notice thereof delivered to the accounting department of Midway Dental Supply, which notice must actually be received. Until I provide such notice, I agree to be liable for all purchases made on the account(s) established in my name. I understand that Midway Dental Supply reserves right to change my discount pricing should my account become delinquent over 90 days. I hereby authorize Midway Dental Supply to charge my credit card or withdraw from my bank account provided above upon shipment of each order. By providing email address above, Customer agrees to receive monthly statements via email. Customer must contact AR@midwaydental.comto receive paper statements instead.

Email *

Office Address

Where your supplies go!

Office Name *

Office Phone *

Office Street Address *

State *

City *

Zip code *

Same Billing Address? *

Doctor Credentials

Let's get clinical.

License Number *

License Date *

License State *

Doctor Name *

Payment

Cash or Credit?

Account Payable Name *

Account Payable Email *

Account Payable Phone *

Pay by ACH or Credit Card? *

ACH Payment Details

No credit cards here!

ACH Checking or Saving? *

Account Holder Name *

Account Number *

Account Routing Number *

Bank Address *

Do We Agree?

The final step!

Do you agree to Midway's Terms & Conditions? By Selecting 'Yes' the person's name entered into question 2 agrees to the terms & conditions listed at the top of this form and is counted as a signature.