USA Lab Wholesale Application

Name & Address

First Name *

Last Name *

Title *

Company Name *

Address *

City *

State/Province *

ZIP/Postal Code *

Phone Number *

Email Address *

Company Web Site

Tax I.D. Number

In Business Since *

YYYY

Legal Form Under Which Business Operates *

Corporation

Partnership

Proprietorship

Other:

Business Name *

Address *

City *

State/Province *

ZIP/Postal code *

Bank Information

Institution Name *

Name on Account *

Phone Number *

Account Type *

Account number *

Routing Number *

Trade Reference #1 (1 of 3)

Company Name *

Contact Name

Address *

Phone number *

Account Opened Since

YYYY

Credit Limit

Current Balance

Trade Reference #2 (2 of 3)

Company Name *

Contact Name

Address *

Phone number *

Account Opened Since

YYYY

Credit Limit

Current Balance

Trade Reference #3 (3 of 3)

Company Name *

Contact Name

Address *

Phone number *

Account Opened Since

YYYY

Credit Limit

Current Balance

Financial Information

Total Sales Annually *

Monthly Order Frequency / Dollar Amount *

Is Your Company Subject to any Litigation? *

Yes

Other:

Required

Agreement

We declare that the above information is true, correct and complete. We authorize USA Lab to contact trade references and banks for verification. We authorize all banks and references to disclose to USA Lab all information concerning the financial and credit history of my company and myself.

Company Name *

Title *

Agreement *

I have read the terms and conditions stated and agree to all terms and conditions.

Required

Submit

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