Essence Dental Studio > Apply for membership

Please fill out this form : (* : Required)

We contact our customer by Email only, so please fill in your daily-used email address.

Doctor's full name *    
Clinic's name *    
Doctor's practice license number *    
Primary email address *    
Secondary email address      
Phone number *    
Fax number *    

Mobile number

      
Address *    
City *    
State * ex:NV    
Zip * ex:89074    
Contact person name      
Login username (max 25 chars) *    
Login password (max 25 chars) *    
Retype password again *    
Question for lost password *    
Answer for above question *    
Are there any unsatisfied judgements against you ? *
Have you been declared bankrupt in the last 14 years ? *

Reference 1 : Please provide one of the names of those dental lab you buy from an open account

Business *    
Phone *    
Address *    
City *    
State * ex:NV    
Zip * ex:89074    
 

Reference 2 : Please provide the names of those dental lab you buy from an open account

Business *    
Phone *    
Address *    
City *    
State * ex:NV    
Zip * ex:89074    

Online Registration Form

You must read and agree to our Terms & Policies to be able to submit the Online Registration Form.
*

TERMS & POLICIES

By signing or sending this Online Registration Form to Essence Dental Studio,LLC, I agree to abide by all terms and policies listed below. I/we will affirm that the foregoing information contained in this application is presented for the purposes of establishing credit and is true, complete, and correct. Essence Dental Studio,LLC is authorized to make any investigation of my credit or employment status whether directly or through any agency employed by Essence Dental Studio,LLC for that purpose. You may also disclose to any other interested parties or agencies your experience with this account. I/we agree to inform Essence Dental Studio,LLC immediately of any matter, which will cause significant change in my financial condition on existing or new orders. I/we understand Essence Dental Studio,LLC will retain this credit application whether or not it is approved. If this application is approved by Essence Dental Studio,LLC, I/we agree to the following terms:

A.) All invoices will be paid promptly within 15 days of receipt.

B.) Any Invoice, which is not paid when due, will accrue interest of one and one half percent (2%) per month on the unpaid balance from the invoice date, until payment is received.

C.) In the event the company is a corporation, I/we understand that by signing below, I/we personally guarantee payment of any and all monies owed on account.

D.) In the event that it becomes necessary to file an action to recover any amounts due under this agreement, I understand and agree that the court shall award prevailing party in such action, all costs including reasonable collection and attorney fees.

E.) This agreement shall be governed by, and consulted and enforced under the laws and judicial decisions of the state of California . Any and all actions to enforce this agreement shall be commenced in the county of Los Angeles .

F.) This agreement shall act as a revolving agreement, and shall apply to any and all future orders placed with Essence Dental Studio,LLC by the applicant.

G.) This agreement shall be binding on and shall insure to the benefit of heirs, executors, administrators, successors or assigns of the respective parties.

H.) Only a written instrument executed by an authorized credit officer of Essence Dental Studio,LLC may modify the terms of payment and credit as specified herein.