NEW ACCOUNT INFORMATION FORM

Fill out & send back to ar@2mfg.com or Fax to 602.437.2270

If you have any questions, please call us at 1.800.833.4419

Company Name
Billing Address
City State Zip Code
Shipping Address
City State Zip Code
Telephone ( ) Fax ( )
Parent Company (if applicable)
City State Zip Code

KEY PERSONNEL (Please give full name): TYPE OF BUSINESS:

Buyer/Purchasing Agent Distributor Hospital/Medical CTR Other
Accounts Payable Mgr CA Sales Tax Exempt. #
Accounts Payable Rep MO Sales Tax Exempt. #
Owner’s Name Years in Business
Credit Limit requested: $
Email address to send shipping confirmations
Fax/Email address to send invoicing

I (we) have completed this application and certify that all statements contained therein are true and correct. I (we)
agree that credit inquiries may be made and authorize the release of such information to you. I (we) understand and
agree that any credit granted shall be paid promptly in accordance with credit grantor terms and agreements. I (we)
also understand and agree that credit grantor may add legal rate of interest per month to any balance not paid in
accordance with said terms and agreements. I (we) also agree, in the event of default, to pay reasonable collection
charges, attorney fees and court costs where applicable.

Authorized Signature Date

Please Print Name Title

Where did you hear about Waterloo Healthcare? (Please list the name of the specific referral source)
Magazine Ad Trade Show Internet
Word of Mouth Other

Waterloo Healthcare www.WaterlooHealthcare.com 1.800.833.4419

 Form W-9 Request for Taxpayer Give Form to the
requester. Do not
(Rev. December 2014)
Department of the Treasury Identification Number and Certification send to the IRS.
Internal Revenue Service
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

See Specific Instructions on page 2.

3 Check appropriate box for federal tax classification; check only one of the following seven boxes: 4 Exemptions (codes apply only to
certain entities, not individuals; see
Individual/sole proprietor or C Corporation S Corporation Partnership Trust/estate instructions on page 3):
single-member LLC
Print or type

Exempt payee code (if any)

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶
Exemption from FATCA reporting
Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for
the tax classification of the single-member owner. code (if any)
Other (see instructions) ▶ (Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.) Requester’s name and address (optional)

6 City, state, and ZIP code

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other – –
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3. or
Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for Employer identification number
guidelines on whose number to enter.
–

Part II Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 3.
Sign Signature of
Here U.S. person ▶ Date ▶

General Instructions • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T
(tuition)
Section references are to the Internal Revenue Code unless otherwise noted. • Form 1099-C (canceled debt)
Future developments. Information about developments affecting Form W-9 (such • Form 1099-A (acquisition or abandonment of secured property)
as legislation enacted after we release it) is at www.irs.gov/fw9.
Use Form W-9 only if you are a U.S. person (including a resident alien), to
Purpose of Form provide your correct TIN.
An individual or entity (Form W-9 requester) who is required to file an information If you do not return Form W-9 to the requester with a TIN, you might be subject
return with the IRS must obtain your correct taxpayer identification number (TIN) to backup withholding. See What is backup withholding? on page 2.
which may be your social security number (SSN), individual taxpayer identification By signing the filled-out form, you:
number (ITIN), adoption taxpayer identification number (ATIN), or employer
1. Certify that the TIN you are giving is correct (or you are waiting for a number
identification number (EIN), to report on an information return the amount paid to
to be issued),
you, or other amount reportable on an information return. Examples of information
returns include, but are not limited to, the following: 2. Certify that you are not subject to backup withholding, or
• Form 1099-INT (interest earned or paid) 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If
applicable, you are also certifying that as a U.S. person, your allocable share of
• Form 1099-DIV (dividends, including those from stocks or mutual funds)
any partnership income from a U.S. trade or business is not subject to the
• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) withholding tax on foreign partners' share of effectively connected income, and
• Form 1099-B (stock or mutual fund sales and certain other transactions by 4. Certify that FATCA code(s) entered on this form (if any) indicating that you are
brokers) exempt from the FATCA reporting, is correct. See What is FATCA reporting? on
• Form 1099-S (proceeds from real estate transactions) page 2 for further information.
• Form 1099-K (merchant card and third party network transactions)

Cat. No. 10231X Form W-9 (Rev. 12-2014)

 SUMMARY OF PAYMENT OPTIONS

1) ACH/Wire Payment
2) Email an image/scan of check (Do not mail in check, but hold until payment clears)
3) Mail in check
4) Credit Card Payment (3% Processing fee applies)

ACH/Wire Transfer
Bank Name: UMB Bank, N.A. (Kansas City, MO)
Bank Address: 2777 E. Camelback Rd., Suite 100, Phoenix, AZ 85016
Account Name: Bergmann Precision, Inc.
Account #: 9872404998
Routing #: 101000695 (incoming Domestic **United States**)
Swift: UMKCUS44 (incoming International)

Email Image/Scan of Check (No International Checks)

• Email check image/scan to ar@2mfg.com for processing
• DO NOT MAIL IN CHECK, but hold until payment clears

Mail Check (NEW STARTING MAY 2020)

PO BOX 641078
Dallas, TX 75264-1078

Credit Card Payment (3% Processing Fee Applies)

• Online credit card payment (Invoices Only): http://www.waterloohealthcare.com/pay
• Call in with credit card payment (Invoices & Prepayments)
855.633.2278 or 602.437.4940

Waterloo Healthcare www.WaterlooHealthcare.com 1.800.833.4419

 TERMS AND CONDITIONS
PLACING YOUR ORDER
• Please fax your order to 602.437.2270 or email to csr@waterloohealthcare.com.
• If a quote was provided prior to ordering, please reference the quote number on the order.
• You will need to have an account with Waterloo to place an order. If you do not have an account, please contact
Customer Service at 1.800.833.4419.

TERMS OF SALE
• Net 30 days for regular customers with approved credit. Other payment terms must be requested.
• Visa, MasterCard and American Express credit cards are accepted. Credit card processing fees may apply.

PRICING
• Pricing is subject to change without notice and products are priced “each” unless otherwise noted. When calling
our Customer Service Department please confirm your price listings are current.

SHIPPING TERMS
• Our Standard shipping terms are F.O.B Phoenix, AZ or Nogales, AZ.
• Stock items can be shipped within two days after receipt of your order.
• Whenever possible, we ship via UPS Ground Service. For emergency orders, we will gladly ship your order via UPS
Air for guaranteed delivery.
• All orders that require a pallet will ship via common LTL carrier.

RETURNED GOODS
• All returned goods must have an authorization number (RMA) assigned by our Customer Service Department.
• Returns must be requested within 30 days from date of original shipment and must arrive no later than 45 days
from date of original shipment.
• Please refer to your purchase order number when requesting an RMA.
• All returned goods must be sent prepaid. Any return that is not prepaid will be refused.
• Any cart with electronic or pushbutton locking systems, large or custom orders, carts that have been modified or
tampered with as well as medication carts are subject to contract and are Non-Returnable.

RESTOCKING CHARGE
• A restocking fee (25%) may be charged to your account for returned merchandise.
• If we shipped incorrect merchandise, there will be an exception to the policy. In this case, please call our
Customer Service Department and report the incorrect shipment.

STOCKING FEES
• Waterloo’s warehouse is setup for manufacturing and not distribution storage. Stocking fees may apply if Waterloo
is asked to store and hold carts that are ready for pick up.
• The stocking fee is $25.00 per cart, per day and is subject to change without written notification.
• Waterloo will notify the customer if they are at risk of incurring stocking fees.

Waterloo Healthcare www.WaterlooHealthcare.com 1.800.833.4419

 TERMS AND CONDITIONS
DAMAGED OR MISSING GOODS CONT.
• All damages must be reported to WHC on the day the items are delivered.
• You have 15 days from the delivery date to report any missing items to WHC.
• If you receive a shipment via truck, inspect all cartons at the time of delivery. If you receive a package that you
believe is damaged, we ask that you do not sign for it. Open all packaging and if there is any damage, call
1-800-833-4419 as soon as possible. You should make note of all possible damages on Carrier’s Delivery Receipt or
Bill of Lading.
• You may be asked to take pictures of the damage to send to WHC to file a claim.
• Please save all boxes and packing materials to show that the items were packed properly.
• 3rd Party and Collect freight damages and lost items are the responsibility of the customer.

PRODUCT WARRANTIES
• Waterloo Healthcare (Seller) warrants the products it manufactures to be free from defects in material and
workmanship under normal and proper use and service for a period not exceeding 5 (five) years from the date
of delivery to the original location.
• This warranty does not apply to any product that has been subject to abuse, misuse, negligence, modification,
normal wear or an accident (dents and scratches are considered normal wear).
• Electronic (WIFI & NON-WIFI) components and plastic components have a one (1) year warranty under the
aforementioned conditions of use.
• The Seller’s liability is limited to the cost of the repair or replacement of any products (at its factory) which fail
to comply with the foregoing warranty. In no event shall the seller be liable for any consequential damages
claimed as a result of breach of the foregoing warranty.
• The Purchaser must reference the original purchase order number or Seller’s invoice on any claims. The Seller
will determine if the products should be returned to the factory or if parts should be sent to the customer for
repair of the product.
• The warranty stated herein is in lieu of all warranties, expressed or implied, including but not limited to
merchantability or fitness for a particular purpose.

ADDITIONAL TERMS FOR INTERNATIONAL ORDERS

PAYMENT
• The majority of international orders are cash in advance via wire or credit card
• Fees may or may not apply
• Cash against documents for orders over $7,000.00 or irrevocable letter of credit at sight for orders over
$15,000.00 is available.

EXPORT PACKING & DOCUMENTATION FEES

• Additional fees may be assessed to sales order to cover special packing requirements for export and additional
documentation costs for customs clearance

Waterloo Healthcare www.WaterlooHealthcare.com 1.800.833.4419