MRI & CT Credit Application

Please fill out the following form as completely as possible. When finished, print, sign, and fax to (469) 519-2497 Att: Credit Department.

Company Details

Are you a: CORPORATION

Names, Titles, Contact Numbers of your Three coporate Officers

Partnership

Company Address (No PO Boxes please)

Your Bank Account Details

Trade References

I represent that the above information is true and is given to induce to extend credit to the applicant. My company and I authorize to make such credit investigation as sees fit, including contacting the above trade references and banks and obtaining credit reports. My company and I authorize all trade references, banks, and credit reporting agencies to disclose to any and all information concerning the financial and credit history of my company and myself. 

Authorized Signature    _____________________________________________