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To set up a customer account with net 30 terms (subject to credit review and approval), please fill out the application form below. Filling out an application is easy and usually takes less than 10 minutes.

If you have any questions, please contact our corporate offices at 800-828-8008. Or email us at credit@bellmed.com

* All fields marked with an asterisk are required to be filled out before the form can be submitted.
Business Information


*How should we invoice you?

Mail invoice to billing address above
Business Owners or Officers
1)
2)
1) 2)
Trade References
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2)
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1) 2) 3)
1) 2) 3)
*Do You Qualify For Tax Exemption?

If yes, please send us a copy of your sales tax exemption certificate:
Email: credit@bellmed.com
Or upload a copy here: (PDF Required)

*I accept Bell Medical Supplies Terms and Conditions?

If no, please upload a PDF copy of your terms and conditions for our review:

*Do you have a DBA License?

*Please send us a copy of your Physician or DBA License:
Email: credit@bellmed.com
Or upload a copy here: (PDF Required)

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