THOMAS SCIENTIFIC

APPLICATION FOR CREDIT

* REQUIRED

FIELD
*BUSINESS PHONE: *SHIP TO: *STREET *CITY *ZIP *STATE
____ PROPRIETORSHIP

*FIRM NAME *BILL TO: *STREET *CITY *STATE

____ CORPORATION PARENT COMPANY (if applicable) STREET CITY STATE ZIP

*ZIP
____ DIVISION OR BRANCH

____ PARTNERSHIP

*YEAR BUSINESS STARTED

Attach Copy of Sales Tax Exempt Certificate

(if applicable) Federal ID # ______________________ and/or

*Attach W9 Form

Do you or any of your affiliates have an existing Thomas Scientific Account number? If yes, Acct. #___________
ESTIMATED PURCHASES FROM THOMAS Yearly Purchases

*Dun & Bradstreet # ________________________

COMPANY OFFICIALS

% $

*Pres/Owner *Treas./Controller

TRADE INFORMATION
Bank Street *Supplier *Street *Supplier *Street *Supplier *Street *City *City *City City Phone State *Phone *State *Phone *State *Phone *State *Zip *Zip *Zip Zip

*What is your preferred method of payment? *How would you like to receive your invoice?
*Name *Phone
Sales Territory No. Sales Rep. Name First Order ($) Freight Info. Date

Electronic Funds Transfer or Check Email __________________ or Fax _____________

*Email *Fax

YOUR ACCOUNTS PAYABLE CONTACT INFORMATION

THOMAS SCIENTIFIC USE ONLY

Account No. D & B Rating Credit Limit ($) Credit Manager Date

THOMAS SCIENTIFIC 1654 High Hill Road P.O. Box 99 Swedesboro, NJ 08085-0099, USA Phone: 800.345.2100 Accounting Fax: 856.467.7647 Questions? Contact: Peggy White, Credit Manager at: PeggyW@thomassci.com
Authorized Signature: ________________________________________________________ Date: _______________________________ Print Name: ________________________________________________________________ Rev. 01/2013

THOMAS SCIENTIFIC

ACCOUNT USER PROFILE

We want to better assist you, our customer. To help us stay connected with you, please complete your user profile(s) below. This information will be placed into our end-user database to keep customers up-to-date on new products, suppliers and information we feel may be of interest to you. We do not share your information with third party companies.
* REQUIRED *Company *Email *Street *Industry *City

FIELDS
*Phone *Website *State *Zip

Account User Profiles:

*Name *Title *Phone *Email *City *State *Zip

Complete Address Section if different from Company Mailing Address above

*Street

*Name *Title

*Phone *Email *City *State *Zip

Complete Address Section if different from Company Mailing Address above

*Street

*Name *Title

*Phone *Email *City *State *Zip

Complete Address Section if different from Company Mailing Address above

*Street

*Name *Title

*Phone *Email *City *State *Zip

Complete Address Section if different from Company Mailing Address above

*Street

Thank you for providing Thomas Scientific with this information. We believe you are important and we invite you to experience the difference that Thomas Scientific can make.

Rev. 01/2013