CLIENT PROFILE
 
Complete ALL information below and one of our marketing associates will promptly respond to your request.
Should you have questions, email us at marketing@theramaxtherapyservices.com, or fill-out the CONTACT US  form.
All client information is kept confidential and will not be used for any purposes other than client eligibility.
We look forward to doing business with you.
 
The Company Legal Name :      
Tax payer number:      
Type of Entity:         
Nature of Business:      
Main Office Address:      
Phone Number:      
Fax Number:      
Email Address:      
 
Name/s of the principal of the Company, their complete address/es and telephone number:
Full Name :         
Best Contact Number:         
Email Address:         
 
Person to contact about the account:
Check if same as the principal of the company     note : If checked, Go to Trade References
Full Name :    Best Contact Number :   
Fax Number :    Email Address :   
 
Trade References: (A minimum 1 year credit history, 2 references must be a therapy staffing company currently used)
Full Name :    Best Contact Number :    Email Address:   
Full Name :    Best Contact Number :    Email Address:   
 
 
I/ we warrant that the firm is solvent.
I/ we warrant that no owner (if a partnership or proprietorship) and no officer (if a corporation) has been the subject of a personal bankruptcy in the last 10 years and that the firm is not in any bankruptcy.
It is understood that Theramax policy requires that an update of the application will be provided every 12 months by the applicant firm.
I/ we authorized you to investigate the information I have supplied with this Application and access any credit reporting agency for which you are a member, in your investigation on me, the shareholders or my company not just at the time of setting up of the account but from time to time as may be needed, in the credit evaluation process.
I warrant that the foregoing information is true and correct and realize it will be relied upon in the granting of future credit.    
 
 
By checking this box and typing my name, I am electronically signing my form and asserting that all information provided by me is true and accurate.
 
 Signature : ,Individually              Date: (mm/day/year:)
                   (Type your complete name here)
                              
Kindly Input code :    
 
Confidentiality Notice:
THIS INFORMATION CONTAINED IN THIS FORM IS CONFIDENTIAL AND/OR PRIVILEGED. IF THE READER OF THIS TRANSMITTAL PAGE IS NOT THE INTENDED RECIPIENT OR A REPRESENTATIVE OF
THE INTENDED RECIPIENT, YOU ARE HEREBY NOTIFIED THAT ANY REVIEW, DISSEMINATION COPYING OF THIS FORM OR THE INFORMATION CONTAINED HEREIN IS PROHIBITED. IF YOU RECEIVED
THIS COMMUNICATION IN ERROR, PLEASE NOTIFY THE SENDER IMMEDIATELY BY TELEPHONE AND DESTROY ALL COPIES OF THE ORIGINAL MESSAGE. THANK YOU