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Credit Application
   

 

Credit Application Form

Please Note: Chemglass Life Sciences Credit Terms are NET 30 Days.

   
Shipping Address:
   
Company Website:
Federal ID No.:
Dun & Bradstreet No.:
  Accounts Payable Contact Information
Contact Name:
Contact Email:
Contact Phone No.:
TAX EXEMPT STATUS If you answer NO, you must provide a copy of your Tax Exemption Certificate.
Should we charge you sales tax?
   
Type of Business (Please check only one.)  
   
CREDIT REFERENCES - If your company has been in business for less than three years, please provide a minimum of three references.
Please do not use VWR, Fisher Scientific or Sigma-Aldrich as they do not supply credit data.
   
Number of Years In Business:
   
  Name Phone No. Fax No.
1.
2.
3.
   
Submitted By:
Contact Email:
Contact Phone No.:

Enter current year to confirm you are not a robot(YYYY)