VTL Chemical Representative*

please write in the name of the chemical representative you are working with

BILLING INFORMATION

Business Name*

Business Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Phone*

Business Owner*

First Last

Date Business was Established*

Requested Credit Line (whole dollar amounts)*

SHIPPING INFORMATION

Business Name*

SHIPPING Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Phone*

INVOICE & ORDER CONFIRMATION

Accounts Payable Name*

First Last

Accounts Payable Email*

Invoice preference (pick one option)*

I would like my invoices MAILED
I would like my invoices sent via EMAIL

If you have checked that you prefer e-mail, the invoices will be sent to your Accounts Payable contact. If you would prefer to have invoices emailed to someone else or add a CC contact, please specify email addresses below:

Order Confirmation Emails should be sent to the following address(es):*

SHIPPING INSTRUCTIONS

Check all that apply*

Lift gate required for deliveries. (additional fees may apply)
Forklift on site.
Appointment required for deliveries. (additional fees may apply)
No special shipping instructions needed.

If an appointment is required, please provide contact information to schedule deliveries:

Please indicate Shipping and Receiving Hours (e.g. 8:00 am - 3:00 pm, 12:00 noon - 6:00 pm, etc. )*

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. *** PLEASE NOTE THAT IF A CUSTOMER FAILS TO BE ON-SITE FOR DELIVERY AND THE CARRIER MUST RETURN, THERE WILL BE A REDELIVERY FEE OF $200.00 CHARGED TO THE CUSTOMER. IF AN APPOINTMENT IS REQUIRED, THIS CAN DELAY SHIPMENT. ***

TAX EXEMPT STATUS

If you are tax exempt you must include a copy of you state tax exempt certificate along with this credit application form at the time of submission. If no tax exempt certificate is submitted our default will automatically place your account on taxable status. If you submit a certificate after we have processed invoices, from that day forward you will be tax exempt. We will not credit tax already incurred on invoices prior to submission of your tax exempt certificate. Tax exempt certificates should be emailed to golson@ver-techlabs.com or faxed to 763-559-1438.*

YES - this business is tax exempt.
NO - tax exempt status is NOT applicable

TRADE REFERENCES

NAME OF TRADE REFERENCE #1 (Business name)*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Contact*

First Last

Email*

NAME OF TRADE REFERENCE #2 (Business name)*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Contact*

First Last

Email*

NAME OF TRADE REFERENCE #3 (Business name)*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Contact*

First Last

Email*

Applicant(s) Acknowledgement

The above information is for the purpose of obtaining credit and is warranted to be true. I (we) hereby authorize Ver-tech Laboratories, Inc. to investigate the references listed pertaining to my (our) credit and financial responsibility. Information obtained will be held STRICTLY CONFIDENTIAL. Applicant's submission of this form attests financial responsibility, ability and willingness to pay our invoices in accordance with Ver-tech Laboratories, Inc. terms and further agrees to pay all collection costs and attorney’s fees necessary to collect past due amounts, as permitted by law.*

I AGREE to the Terms and Conditions
I DISAGREE to the Terms and Conditions

Applicant Name and Title*

Date*

Additional Applicant Name and Title

Date

Additional Applicant Name and Title

Date

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Please complete this form if you would like to apply for credit terms. Payment is due within 30 days of Invoicing.

Application - Credit Terms Customer

BILLING INFORMATION

SHIPPING INFORMATION

INVOICE & ORDER CONFIRMATION

SHIPPING INSTRUCTIONS

TAX EXEMPT STATUS

TRADE REFERENCES

Applicant(s) Acknowledgement