Credit Application Form

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

Check box for credit card terms only

Company:

Billing Address 1:

Address 2:

Billing City:

Billing State:

Zip Code:

Billing Country:

Shipping Address: Same as billing

Shipping Address 1:

Address 2:

Shipping City:

Shipping State:

Zip Code:

Shipping Country:

Phone Number:

Fax:

Company Website:

Federal Id:

Dun & Bradstreet ID:

Accounts Payable Contact Information

Contact Name:

Contact Email:

Phone Number:

Tax Exempt Status

Charge me sales tax: If you do not check this box, you must provide a copy of your Tax Exemption Certificate

Type of Business:

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.

Years in Business:

Name: 1. 2. 3.
Phone Number: 1. 2. 3.
Fax Number: 1. 2. 3.
Email: 1. 2. 3.

Credit Application Form

Accounts Payable Contact Information

Tax Exempt Status

Credit References

Information

products

Customer service

My account