Account Application
 
In order for SPS to continue serving our customers with the highest quality care possible, all of our customers are required to set up an open account.  This not only provides our customers with more payment options, but it also allows SPS to determine which products are best suited for our customers' needs.
 
You may complete the quick form below or download the Microsoft Word version of the Account application and fax it to us.
 

Download Form

 
SPS Credit / Account Application
Required Fields Highlighted in red
 

Bill To Information:

   
    Name of Business:
Address:
City/State/Zip:
Country:
   

Ship To Information (If different from Bill To Information):

 
Address:
City/State/Zip:
Country:
 
Point of Contact
 
Contact Name:
Email:
Phone:
Fax:
 
General Information
 
Type of Business:
 (i.e. Prosthetic and/or Orthotic Patient Care, Central
Fab, DME, Medical Supply, etc.)
Name & Certification #:
(CP, CO, CPO, BOC, etc.)
Year Bus. Started:
# Yrs. Present Location:
Fed ID #
A/P POC Name:
A/P POC Phone:
A/P POC Email:
Has the company
or principal ever been
bankrupt?
 
Type of Organization: Sole Proprietorship Partnership Corporation
Publicly Traded

If not publicly traded, identify principle owners:
Principal Owners or Officers
 
Name #1:
Social Security Number #1:
Title #1:
Address #1:
Phone #1:
Email #1:
 
Name #2:
Title #2:
Social Security Number #2:
Address #2:
Phone #2:
Email #2:
  
Bank Information
 
Bank Name:
City:
Bank Contact:
Bank Phone:
Bank Fax:
Account Numbers:
 
Trade References
 
Firm #1:
Phone:
Account #:
Address:
Fax:
 
Firm #2:
Phone:
Account #:
Address:
Fax:
 
How did you hear of SPS?
 
Anticipated Monthly
Purchases from SPS:
 

To complete your application, an authorized signature is required.
Please download the Authorization form in either MS Word or pdf format, sign and fax to 800-779-4935.

 

Toll Free: (800) 767-7776 ext. 3
Worldwide: (678) 455-8888 ext. 3
After Hours Emergency: (877) 317-4570