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New Customer Worksheet (NC)

New Customer Worksheet for Non-Credit Customers

Use this form if you do not wish to apply for a credit account with Protective Equipment Testing Laboratory.

Customers of this group will be required to pay for services at the time they are rendered. If you would like NET30 terms or similar, please complete the New Customer Worksheet for Credit Customers instead.

PLEASE NOTE: We will call you for credit card billing information before we ship your items back to you.

* = REQUIRED FIELD

Contact Information:

* Name of Company:

* Billing Address:

* May we email your invoices? Yes No

* Email Address:

* Shipping Address:

* Phone Number:

Fax Number:

Responsible Party

* Name:

Job Title:

* Phone Number:

Fax Number:

Email Address:

Frequency of Testing

Rubber Gloves: 30 Days 60 Days 90 Days 120 Days 180 Days

Approximate Number of Pair:

Rubber Sleeves: 30 Days 60 Days 90 Days 120 Days 180 Days

Approximate Number of Pair:

Do you use employee or item numbers on your gloves and sleeves? Yes No

Rubber Cover-up: 30 Days 60 Days 90 Days 120 Days 180 Days

Hot Sticks 180 Days Annually Bi-Yearly

Replacements

*Please note testing fees are different for replacement customers and non-replacement customers.

* Do you want failed items replaced? Yes No

Truck Inspection

Number of Trucks:

Frequency of Testing: 6 Months Annually

Name of Person Responsible for Truck Inspections (If Applicable)

Name:

Job Title:

Phone:

Fax:

Email Address:

Terms and Conditions

This is a NON-CREDIT worksheet. Any fees charged to this account are due immediately. PETL will contact you for credit card billing information before shipping your items back. Any amount that is past due will be charged a 1.5% per month finance charge, with a minimum of $5.00 per month until all debt is paid in full. Any collection costs, attorney fees, and court expenses will be your responsibility and added to the unpaid balance.

By submitting this form, you agree that your typed signature below will have the same full legal force and effect as your handwritten signature. Signing this agreement indicates your acceptance of the terms and conditions as stated.

This form will not be processed without a signature.

* Name of Authorized Representative:

Title:

* Signature (Type your name here):

* Todays Date:

Are You Human?

Thank you. Your information has been submitted and will be reviewed immediately. Please expect to be contacted soon.

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