New Customer Credit Application Form

New Account/General Inquiry Form

"*" indicates required fields

*Indicates a required field

Business Information

Name of Business*

Legal (If Different):

Billing Address 1*

Billing Address 2

City*

State

Zip*

Phone*

Fax

DUNS & Bradstreet Numbers (DUNS)

How did you hear about Quality Biological, Inc.?*

Description of Business

Number of Employees

Credit Requested

In Business Since

Type of Business

Business Structure

Sole proprietorship

Partnership

Corporation

Other:

If other, please specify:

Bank Reference

Name of Bank

Branch

Account #

Contact Name

Contact Phone

Contact Fax

Trade Reference

Contact Name 1

Company Name 1

Account Open Since 1

Phone 1

Fax 1

Contact Name 2

Company Name 2

Account Open Since 2

Phone 2

Fax 2

Contact Name 3

Company Name 3

Account Open Since 3

Phone 3

Fax 3

Purchasing Department Information

Purchasing Agent*

Email Address*

Phone

Fax

I confirm that the above information is accurate and allow the release of this information for verification. *

Untitled

I agree

Policy Statement: Initial order for new accounts will not be processed unless accompanied by the above requested information.

Terms: Net 30 days from date of invoice unless otherwise stated. Any unpaid invoice more than 30 days past due must be paid by credit card.

Terms and Conditions

Company Name

Bill to Address 1

Bill to Address 2

City

State

Zip

Accounts Payable Contact*

Accounts Payable Email*

Accounts Payable Phone*

Accounts Payable Fax*

Special Invoice Requirements if Applicable

Name of Person Completing This Form*

Title*

Phone*

Email*

Term: Net 30 from the date of the invoice unless otherwise stated. Any unpaid invoice more than 30 days from the date of the invoice will be subject to a charge of 1.5% per month, which is an 18% annual rate and will be charged to credit card on file.

Returns: All returns must be authorized by Quality Biological, Inc. prior to return. This authorization is necessary to ensure correct return of materials and issuance of credit or exchange of materials. Before returning items, please call Customer Service for Return Authorization Number. Returns will not be accepted without prior authorization. Items must be returned within 15 days of receipt in the original packaging and re-sellable condition. Pre-sterilized products that have been opened cannot be returned. All returns due to incorrect quantities ordered or incorrect product ordered will be subjected to a 25% restocking fee.

Claims: Please inspect your Quality Biological shipment upon receipt. Do not accept any damaged packages unless the carrier has documented the condition on all delivery receipts. Report any errors or damaged products to Quality Biological within 5 days of delivery.

By submitting this form I acknowledging the terms and conditions as stated above.

Untitled

I agree

Phone

This field is for validation purposes and should be left unchanged.

New Account/General Inquiry Form

Business Information

Description of Business

Bank Reference

Trade Reference

Purchasing Department Information

Terms and Conditions

Email sign-up.