Become an Official Resource Labs Provider

To become an official Resource Labs provider, please fill out the application and optionally the credit application below.

Account Information

Company Name(Required)

DBA

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Ownership(Required)

Federal ID or S.S.#

NPI#(Required)

State Tax ID#

Length of time in business

Names of Principals

Name

Title

Name

Title

Name

Title

If you would like net 30 day terms, please fill out entire form. Three trade references and one bank reference are required to receive credit terms. If you would like to pay by credit card, you may leave the references section blank.

Trade References

Name

Title

Name

Title

Name

Title

Bank Reference

Bank Name

Bank Phone

Bank Contact

Bank Account #

Purchasing

Are purchase order numbers required by your facility?(Required)

Do you have multiple shipping addresses or a shipping address that is different from the address above?(Required)

If yes, please provide a listing of all addresses

Purchasing Contact Information

Purchasing Name

Purchasing Phone

Accounts Payable Contact Information

Accounts Payable Name

Accounts Payable Phone

What products do you intend to order? (check all that apply)

First Step

DynaFlex

Foot Tech

Resource Labs

Other

How Did You Hear About Us?

Wrymark Credit Policy

1. Wrymark Inc. terms are net 30 days. All accounts with a past-due balance of more than sixty (60) days may have orders and shipments held. All payments are credited to your account the date received. Prompt payment of past-due accounts will return them to normal delivery.

2. All past-due accounts are subject to a service charge of one and one-half percent (1.5%) per month (18% per annum).

I/we authorize Wrymark, Inc. to obtain such factual information regarding my credit rating, permitted by law, for this Credit Application or for future Credit Applications, and to retain this data on file.

Signed(Required)

Title(Required)

Date(Required)

Company Email(Required)