Deferment Request

All Walman divisions will defer payments for March 2020 and April 2020 invoices until June 10th, 2020. Accounts eligible for a deferment MUST be in good standing with all Walman accounts through February 2020 to qualify.

To Apply:

Agree to the Account “In Good Standing” Statement

Agree to the Terms & Conditions to order to be considered for deferment

PLEASE NOTE: Completing this form is NOT an approval for deferment. A Walman and/or Division Representative will be in contact with you regarding your request. If approved you will receive confirmation from Walman via email confirming the updated terms to your account(s).

Contact Information:

Practice Name

First Name

Last Name

Email (for all future correspondence)

Phone

Walman Account Information:

Please select which accounts you are requesting deferment from: (Check all that apply) Walman Optical

Walman Instruments

X-Cel Specialty Contacts

ImageWear

PLEASE NOTE: If you are a current ADO Practice Solutions member, this deferment opportunity will only pertain to the Walman divisions you currently have billing through ADO. All other vendor billing terms will need to be addressed on a case to case basis and up to the discretion of those participating vendor partners. As ADO receives adjusted payment terms from vendors, those terms will automatically be applied to members' monthly statements. ADO will automatically be waiving the ADO CORE monthly membership admin fee for April and May 2020, any additional requests beyond the monthly fee will need to be addressed directly with an ADO Practice Solutions representative.

If available, please provide your account number(s) for each division, where applicable.

NOTE: Providing at least one account number will quicken the processing time, so please provide as much information as possible prior to submitting this form.

Walman Optical Account Number:

Walman Instruments Account Number:

X-Cel Specialty Contacts Account Number:

Imagewear Account Number:

Comments/Questions regarding deferment and/or your Walman account(s):

Account 'In Good Standing' Statement:

By checking the box below you are confirming that you are in good standing (no outstanding balances) with the account(s) stated above as of February 2020. Yes - I am currently in good standing with all Walman Accounts listed above.

Terms & Conditions:

I understand that Walman must approve this Agreement and that all charges and payments on my Account will be processed by Walman in Minneapolis, Minnesota. Therefore, the substantive law of the State of Minnesota shall govern this Agreement and my Account. I consent to the jurisdiction and venue of the federal and state courts of Minnesota in Hennepin County as having the exclusive and proper subject matter and personal jurisdiction over this Agreement. I agree to pay all collection fees, reasonable attorneys' fees, court costs, and other expenses incurred by Walman to enforce this Agreement. Yes - I understand and accept the terms & conditions of this agreement.

New code

Please type the code above