Customer Set-up Form - Credit Terms

Are you an existing customer applying for credit terms?*

Yes
No

Account #*

Company Info

Company Name*

*

Ship to Address:

*

Phone	Fax

*

City	County	State	Zip

Same as Ship to Address?*

Yes
No

(Check this box if your Ship to Address is the same as your Bill to Address)

*

Bill to Address:	Phone	Fax

*

City	County	State	Zip

D & B No.

Lab Type*

(Choose your company's lab type)

Enter the Name of Your Hardy Account Manager

Tax Exemption Status*

Resale
Exempt
Taxable

(Resale and Exempt require a certificate at time of application)

Upload your Tax Exemption Certificate*

Estimated Monthly Purchase Amount:*

Please enter an amount greater than $1.

Contact Information

Laboratory Manager

Name	Phone	Fax	Email

Microbiology Supervisor

Name	Phone	Fax	Email

Purchasing Agent*

Name	Phone	Fax	Email

Pricing Contact Email Address*

Order Confirmation Email Address

Accounts Payable Supervisor*

Name	Phone	Fax	Email

Invoice Email Address

Ownership Information

*

Date Established:	Number of Years at this Address:	Number of Employees:

Business Type:*

Corporation
Individual
Proprietorship
Partnership

*

Name of Owner/Officer	Job Title	Address	Phone

Trade References

(Please fill out or attach your company’s standard form.)

Please choose how you will complete your trade references*

Upload your company's form
Fill out fields below

File*

Upload your company’s standard form, or fill out the fields below.

Trade References*

Company Name	Address	City	State	Zip

*

Account Number	Name and Title	Phone	Fax	Email

*

Company Name	Address	City	State	Zip

*

Account Number	Name and Title	Phone	Fax	Email

*

Company Name	Address	City	State	Zip

*

Account Number	Name and Title	Phone	Fax	Email

Do you have an immediate order to place?*

Yes
No

Attach Purchase Order here:

Disclaimer:

All statements made herein are true and accurate to the best of our knowledge. We are aware that incomplete or false information may result in denial of credit. We authorize Hardy Diagnostics to make any inquiries necessary for action on this credit application. We agree to comply with the stated terms of sale, i.e. net 30 days. Any amount due after 30 days is subject to a late charge of 1.5% per month. In the event that any action is necessary to collect amounts due, Hardy Diagnostics will be entitled to recover all principal due as well as expenses and reasonable attorney fees. Hardy Diagnostics reserves the right to change credit terms at any time without notification. If you have any questions, please contact [email protected]*

I Agree

*

Authorized Signature	Job Title	Date	Email	Phone

Customer Set-up Form – Credit Terms

Customer Setup - Credit Terms (USA Only)

Company Info

Contact Information

Ownership Information

Trade References

Disclaimer:

The HardyBlog

News and Events

Customer Set-up Form – Credit Terms

Customer Setup - Credit Terms (USA Only)

Company Info

Contact Information

Ownership Information

Trade References

Disclaimer:

The HardyBlog

MicroBytes Newsletter

News and Events