Customer New Account Form

Type of Business: (check off those that are appropriate)

☐ Retailer ☐ On-line Only ☐ Retail and On-line
☐ Wholesaler ☐ Manufacturer ☐ Other

Additional Information: Click here to enter text.

Retailer – number of stores: Click here to enter text.
Store Locations: Click here to enter text.

Wholesaler: Type of stores/companies you sell to? Click here to enter text.
Online: What is the website you sell from: Click here to enter text.
Headquarters Location: Click here to enter text.
Phone Number: Click here to enter text.
Years in Business: Click here to enter text.
Number of Employees: Click here to enter text.
Annual Sales: Click here to enter text.

Chaney/AcuRite products of interest: Click here to enter text.

Estimated annual purchases of Chaney Instrument products: Click here to enter text.

www.AcuRite.com  965 Wells St.  Lake Geneva, WI 53147  Telephone: 262-729-4851  Fax: 262-348-0207
Please read and acknowledge your agreement to the following statements:

☐ We reserve the right to restrict our products from being sold on Amazon.com.
 Ecommerce customers are reviewed on a case-by-case basis. We reserve the
right to deny the sale of goods based on prior commitments to our current online
retailers.
☐ We ship direct to your company/warehouse in the USA or Canada.
☐ Opening Order Minimum is $750.00.
☐ All subsequent orders must meet the order min of $350.00 FOB WI.
☐ Freight PPD for orders over $750.00 within USA location or $1,000.00 into Canada
standard freight method, via our preferred carrier.
☐ Lead time = 3 days from order received date, upon credit or credit card approval.
☐ You may place your orders by fax 262-348-0207, or email to orders@chaney-inst.com.
☐ Payment terms are credit card (note: Chaney does not hold cc information).

☐ Tax ID / Resale Certification required

Payment Terms: Net 30 days (Upon credit approval)

 Requires $3,000 in sales or more annually
 Completed credit application is required

Signature: _____________________________________________________________
Print Name: Click here to enter text.
Title: Click here to enter text.
Company Name: Click here to enter text.
Date: Click here to enter text.
eMail Address: Click here to enter text.

Thank you for your business with Chaney Instrument Company.

Sincerely,
Chaney Instrument Company
Customer Service Department

www.AcuRite.com  965 Wells St.  Lake Geneva, WI 53147  Telephone: 262-729-4851  Fax: 262-348-0207