Application - Credit Card Customer

Please complete this form if you would like to pay your invoices with a credit card. Your credit card remains on file with Ver-tech Labs and payment is run automatically at invoicing.

VTL Chemical Representative*
please enter the name of the chemical representative you are working with
Business Name*
Business Owner*
First Last
Email
Phone
Business BILLING Address (where Invoices will be sent)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
TAX EXEMPT STATUS
Please select the status from dropdown*
INVOICE & ORDER CONFIRMATION
Accounts Payable Name*
First Last
Accounts Payable Email*
Select Invoice Delivery Method from dropdown*
Invoices will be sent to the Accounts Payable email address. If you would like other individuals to receive an e-mail copy of the invoice, please list their e-mail addresses:
Order Confirmation Emails should be sent to the following address(es):*
SHIPPING INFORMATION
Check here if Shipping Address is SAME as Billing Address
- Yes - both are the SAME address
Business Name
Shipping Address - Location where products will be shipped to; if the wrong address has been entered and the shipment has been redirected, you will be charged a redirect fee (approximately $200.00).
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number for the Driver Delivering Product*
Check all that apply*
- This address requires a lift gate. (additional fees may apply)
- This address has a forklift on site.
- This address has a dock. (additional fees may apply)
Please list any additional shipping instructions. Please note that additional shipping requirements can potentially delay shipments. Based upon your identified requirements, additional shipping costs may be incurred.
Would you like to sign up for our newsletter?
- Yes, I'd like to receive the Ver-Tech Labs newsletter.

Application – Credit Card Customer

TAX EXEMPT STATUS

INVOICE & ORDER CONFIRMATION

SHIPPING INFORMATION

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