Exquisite Dental Studios Inc. New Client Agreement. Required for new accounts. Doctor Name(Required) Dental Practice License#(Required) Email Address(Required) Address(Required) City(Required) State(Required) Zip(Required) Phone(Required) Years Established(Required) Ownership(Required)Choose SelectionCorporationPartnershipProprietorshipOther Doctors in Your Practice (list each)My/Our digital signature(s) will affirm that the foregoing information contained in this application is true, complete and correct. I/We agree by signing below to the terms set forth in this document by Exquisite Dental Studios, Inc. All invoices will be paid on a net 15 day basis by automatic American Express Card payment using the card information provided. I agree that Exquisite Dental Studios will automatically charge my card for each prior month’s billing on the 15th of the following month Any invoice that is not paid due to lack of funds, will accrue interest until payment in full is received. In the event the company is a corporation, I understand and agree that by siguing below I personally guarantee payment of any and all monies owed. In the event that it becomes necessary to me an action to recover any amounts due under this agreement, I understand and agree that any and all court costs, including reasonable attorney fees will be my responsibility. This Agreement shall be governed by and consulted and enforced under the laws and judicial decisions of the state of Pennsylvania. Any and all actions to enforce this agreement shall be commenced in the county of Northampton. This Agreement shall act as a revolving Agreement and shall apply to any and all future orders placed with Exquisite Dental Studios, Inc. by applicant. This Agreement shall be binding on and shall insure to the benefit of heirs, executors, administrators, successors or assigns of the respective parties. Agreement of Terms I agree to the above termsSignature (type your name)(Required) Title(Required) Date(Required) MM slash DD slash YYYY CAPTCHA