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Credit Application Form

Company Information

Tax Exempt
Business Type
Ownership Structure
Business Affilliations
Drug License Current?
Payment Method

By signing above, you are attesting that you have the appropriate authority to execute this application on behalf of the applicant, and that the information herein is complete and accurate. Furthermore, you are hereby authorizing Boston Scientific or its assignees to contact any of the credit or trade references listed on this application or other applicable sources regarding the applicant's credit standing. You are also authorizing Boston Scientific to share information contained in this application with its subsidiaries, affiliates, successors and assigns. This application is subject to Boston Scientific’s credit policy, and Boston Scientific at its sole discretion may elect to refuse or to extend credit, or to limit the amount of credit extended.

This agreement and performance by the parties hereunder shall be construed in accordance with the laws of the state of Delaware, USA, without regard to provisions on the conflicts of laws and the parties’ consent to the exclusive jurisdiction of, and venue in, the State and federal courts of Massachusetts.

Boston Scientific reserves the right to charge interest on any amount not paid when due at the maximum rate permitted by applicable law.

The applicant agrees to reimburse Boston Scientific all fees and costs Boston Scientific incurs while seeking legal remedies to protect or enforce its rights under this agreement, including fees associated with collection of any past due payment and agency fees.