|
Client Account Creation Authorization Form
|
|
|
|
|
|
|
| | | |
| | | |
|
Ship to Address (Not P.O. Box)
|
| | | |
| |
| * |
| Alabama | AL |
| Alaska | AK |
| Alberta | AB |
| Arizona | AZ |
| Arkansas | AR |
| British Columbia | BC |
| California | CA |
| Colorado | CO |
| Connecticut | CT |
| Delaware | DE |
| District of Columbia | DC |
| Florida | FL |
| Georgia | GA |
| Hawaii | HI |
| Idaho | ID |
| Illinois | IL |
| Indiana | IN |
| Iowa | IA |
| Jalisco | Jlco |
| Kansas | KS |
| Kentucky | KY |
| Louisiana | LA |
| Maine | ME |
| Manitoba | MB |
| Maryland | MD |
| Massachusetts | MA |
| Michigan | MI |
| Minnesota | MN |
| Mississippi | MS |
| Missouri | MO |
| Montana | MT |
| Nebraska | NE |
| Nevada | NV |
| New Brunswick | NB |
| New Hampshire | NH |
| New Jersey | NJ |
| New Mexico | NM |
| New York | NY |
| Newfoundland and Labrador | NL |
| North Carolina | NC |
| North Dakota | ND |
| Northwest Territories | NT |
| Nova Scotia | NS |
| Nunavut | NU |
| Ohio | OH |
| Oklahoma | OK |
| Ontario | ON |
| Oregon | OR |
| Pennsylvania | PA |
| Prince Edward Island | PE |
| Quebec | QC |
| Rhode Island | RI |
| Saskatchewan | SK |
| South Carolina | SC |
| South Dakota | SD |
| Tennessee | TN |
| Texas | TX |
| Utah | UT |
| Vermont | VT |
| Virginia | VA |
| Washington | WA |
| West Virginia | WV |
| Wisconsin | WI |
| Wyoming | WY |
| Yukon | YT |
|
| |
 | Loading… |
|
| |
|
Billing Address (if different)
|
| | | |
| |
|
| Loading… |
| Alabama | AL |
| Alaska | AK |
| Alberta | AB |
| Arizona | AZ |
| Arkansas | AR |
| British Columbia | BC |
| California | CA |
| Colorado | CO |
| Connecticut | CT |
| Delaware | DE |
| District of Columbia | DC |
| Florida | FL |
| Georgia | GA |
| Hawaii | HI |
| Idaho | ID |
| Illinois | IL |
| Indiana | IN |
| Iowa | IA |
| Jalisco | Jlco |
| Kansas | KS |
| Kentucky | KY |
| Louisiana | LA |
| Maine | ME |
| Manitoba | MB |
| Maryland | MD |
| Massachusetts | MA |
| Michigan | MI |
| Minnesota | MN |
| Mississippi | MS |
| Missouri | MO |
| Montana | MT |
| Nebraska | NE |
| Nevada | NV |
| New Brunswick | NB |
| New Hampshire | NH |
| New Jersey | NJ |
| New Mexico | NM |
| New York | NY |
| Newfoundland and Labrador | NL |
| North Carolina | NC |
| North Dakota | ND |
| Northwest Territories | NT |
| Nova Scotia | NS |
| Nunavut | NU |
| Ohio | OH |
| Oklahoma | OK |
| Ontario | ON |
| Oregon | OR |
| Pennsylvania | PA |
| Prince Edward Island | PE |
| Quebec | QC |
| Rhode Island | RI |
| Saskatchewan | SK |
| South Carolina | SC |
| South Dakota | SD |
| Tennessee | TN |
| Texas | TX |
| Utah | UT |
| Vermont | VT |
| Virginia | VA |
| Washington | WA |
| West Virginia | WV |
| Wisconsin | WI |
| Wyoming | WY |
| Yukon | YT |
|
|
| |
| | |
|
| | |
|
| | |
| | |
|
State/Date of Incorporation
|
| |
|
Years in Present Business
|
| |
|
| Loading… |
| Alabama | AL |
| Alaska | AK |
| Alberta | AB |
| Arizona | AZ |
| Arkansas | AR |
| British Columbia | BC |
| California | CA |
| Colorado | CO |
| Connecticut | CT |
| Delaware | DE |
| District of Columbia | DC |
| Florida | FL |
| Georgia | GA |
| Hawaii | HI |
| Idaho | ID |
| Illinois | IL |
| Indiana | IN |
| Iowa | IA |
| Jalisco | Jlco |
| Kansas | KS |
| Kentucky | KY |
| Louisiana | LA |
| Maine | ME |
| Manitoba | MB |
| Maryland | MD |
| Massachusetts | MA |
| Michigan | MI |
| Minnesota | MN |
| Mississippi | MS |
| Missouri | MO |
| Montana | MT |
| Nebraska | NE |
| Nevada | NV |
| New Brunswick | NB |
| New Hampshire | NH |
| New Jersey | NJ |
| New Mexico | NM |
| New York | NY |
| Newfoundland and Labrador | NL |
| North Carolina | NC |
| North Dakota | ND |
| Northwest Territories | NT |
| Nova Scotia | NS |
| Nunavut | NU |
| Ohio | OH |
| Oklahoma | OK |
| Ontario | ON |
| Oregon | OR |
| Pennsylvania | PA |
| Prince Edward Island | PE |
| Quebec | QC |
| Rhode Island | RI |
| Saskatchewan | SK |
| South Carolina | SC |
| South Dakota | SD |
| Tennessee | TN |
| Texas | TX |
| Utah | UT |
| Vermont | VT |
| Virginia | VA |
| Washington | WA |
| West Virginia | WV |
| Wisconsin | WI |
| Wyoming | WY |
| Yukon | YT |
|
|
|
|
| Loading… |
|
| 09 | 26 | 27 | 28 | 1 | 2 | 3 | 4 |
| 10 | 5 | 6 | 7 | 8 | 9 | 10 | 11 |
| 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 |
| 12 | 19 | 20 | 21 | 22 | 23 | 24 | 25 |
| 13 | 26 | 27 | 28 | 29 | 30 | 31 | 1 |
| 14 | 2 | 3 | 4 | 5 | 6 | 7 | 8 |
|
|
| Jan | Feb | Mar | Apr |
| May | Jun | Jul | Aug |
| Sep | Oct | Nov | Dec |
|
| | | |
| |
|
|
|
| |
|
|
|
|
Name of Owner, Partner and/or Officers responsible for business transactions
|
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
|
| | | |
| | | |
| | | |
| | | |
|
Amount of credit requested
|
|
|
Estimated annual $ volume planned next 12 months
|
|
| | |
|
Frequency of samples to be processed
|
|
|
|
Entire Agreement: This agreement constitutes the entire agreement between all divisions/subsidiaries of
Waypoint Analytical, Inc. for the services to be performed, and supersedes all prior representations and agreements, whether written or oral.
|
|
|
As part of this customer information, permission is hereby granted to access a consumer/commercial credit report, and to contact
any and all of the trade and bank references listed above, together with any other references which may be provided by these trade and bank references. All pricing and service
disputes must be made in writing within 15 days of receipt of invoice. Claims not received within 30 days from receipt of invoice may be refused.
|
|
|
Payment: Payment for services is due within thirty (30) days from the original date of invoice unless otherwise stated herein.
Client promises to pay promptly all such payments.
|
|
|
By signature hereon, the applicant acknowledges having read and understands this application for credit in its entirety and the terms
and conditions relating hereto; and understands and agrees that Waypoint Analytical, Inc. may act in reliance upon the information specified herein; and that the information contained
herein is true and correct to the best of the applicant’s knowledge and belief.
|
|
|
|
|
| |
|
Authorized signature (owner, officer, partner)
|
| | | |
| | |
| * |
|
| 09 | 26 | 27 | 28 | 1 | 2 | 3 | 4 |
| 10 | 5 | 6 | 7 | 8 | 9 | 10 | 11 |
| 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 |
| 12 | 19 | 20 | 21 | 22 | 23 | 24 | 25 |
| 13 | 26 | 27 | 28 | 29 | 30 | 31 | 1 |
| 14 | 2 | 3 | 4 | 5 | 6 | 7 | 8 |
|
|
| Jan | Feb | Mar | Apr |
| May | Jun | Jul | Aug |
| Sep | Oct | Nov | Dec |
| |
| Loading… |
|
|
| | | | |
|
