EmailMe Form - Accu-Test Labs Credit Application

Company Name:

Date Established

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Sales Contact

Email

Phone

Fax

Accounts Payable Contact

Email

Phone

Fax

Where would you like invoices and statements
emailed?

Are Purchase Orders Required

Yes

No

Tax Exempt

Yes

No

If Yes Please Attach Tax Exempt Form

Responsibility

Ownership Type (Check One)

If Corporation, registered to do business in TX (Check one)

Yes

No

Date of Incorporation

State

If Corporation, Are you a Subsidiary or Division

Subsidiary

Division

Will the Parent Company guarantee debts?

Yes

No

Is billing address different than above

Yes

No

Company Name

Billing Address (If Different from Above)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Parent Company Name

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

BANK REFERENCE

Bank Name

Address

City, State, Zip Code

Phone

### - ### - ####

Email

Account Number

Contact

BUSINESS CREDIT REFERENCES

Emails must be provided to be Expedited

Company Name

Address

City, State, Zip Code

Phone

### - ### - ####

Email

Account Number

Contact

References Continued

Company Name

Address

City, State, Zip Code

Phone

### - ### - ####

Email

Account Number

Contact

Please attach more references to form below if more than two

Signature

Clear

Title / Position

Date

MM / DD / YYYY

File Upload