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New Customer Worksheet for Credit Customers

Use this form if you are applying for a new credit account with Protective Equipment Testing Laboratory. All accounts created with this application are subject to NET30 terms, the conditions of which can be found at the end of the application.

Please complete this applications carefully to avoid processing delays.

* = REQUIRED FIELD


Contact Information:  
Name of Company:
Billing Address:
May we email your invoices?     
Email Address:
Shipping Address:
Phone Number:
Fax Number:
Responsible Party
Name:
Job Title:
Phone Number:
Fax Number:
Email Address:
Frequency of Testing  
Rubber Gloves:                    
Approximate Number of Pair:
Rubber Sleeves:                    
Approximate Number of Pair:
Do you use employee or item numbers on your gloves and sleeves?     
Rubber Cover-up:                    
Hot Sticks:        
   


Replacements
*Please note testing fees are different for replacement customers and non-replacement customers.
Do you want failed items replaced?     
Truck Inspection  
Number of Trucks:
Frequency of Testing:     


Name of Person Responsible for Truck Inspections (If Applicable)
Name:
Job Title:
Phone:
Fax Number:
Email Address:
General Information  
Dun & Bradstreet (D&B) Number:
Number of Years In Business:
Do You Require Purchase Order?     
Tax Status  
Is Your Company Tax Exempt?     
If no, what is your tax rate (%)?
If yes, what is your resale registration number?
Upload Resale Certificate


Credit References

*Please note that these references will be checked prior to approving your new account.

Reference 1  
Company:
Phone Number:
Fax Number:
Contact Person:

Reference 2  
Company:
Phone Number:
Fax Number:
Contact Person:

Reference 3  
Company:
Phone Number:
Fax Number:
Contact Person:


Terms and Conditions

All accounts are Net 30. Any amount that is past due will be charged a 1.5% per month finance charge, with a minimum of $5.00 per month until all debt is paid in full. Any collection costs, attorney fees, and court expenses will be your responsibility and added to the unpaid balance.

By submitting this form, you agree that your typed signature below will have the same full legal force and effect of your handwritten signature. Signing this agreement indicates your acceptance of the terms and conditions as stated. In addition, you authorize Protective Equipment Testing Laboratory to make any and all inquiries necessary to process this credit application.


 
This form will not be processed without a signature.

Name of Authorized Representative:
Title:
Signature (Type your name here):