New Customer Setup

Customer Information

Customer Legal Name*

As shown on tax return

Customer Type

Company

Individual

EIN*

SSN*

Business DBA/Trade Name

Sales Rep*

Primary Contact Name*

First Last

Title

Email*

Phone*

Fax

Billling Address

Accounts Payable Contact Name*

First Last

Phone

A/P Email*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Shipping/Service Address

Same as previous

Payment Terms

Does your organization require purchase orders?*

Yes

No

PO Required on orders totaling more than:

Is your organization exempt from Texas Sales and Use Tax?*

Yes

No

Tax Exemption Certificate

Accepted file types: pdf, jpg, jpeg, png, Max. file size: 50 MB.

Please upload your tax exemption certificate

Preferred Method of Payment

Check

Credit Card (3% processing fee may apply)

ACH (please submit authorization form)

Authorization

Authorization*

By clicking below, I certify that the above information is true and accurate to the best of my knowledge. I also certify that I am an authorized agent and allowed to execute this Customer Information Form. I understand and agree to the terms set forth in this agreement, agree to pay, and specifically authorize to charge my bank account for the services provided. I further agree that in the event my banking information becomes invalid, I will provide updated payment information upon request, to be charged for the payment of any outstanding balances owed, and that I may be subject to penalties resulting from late payment. Return and Privacy Policies are available for review at https://safetymed.com/about-us/.

I agree

Name*

First Last

Title

Hidden

User IP

Hidden

Date

CAPTCHA

Customer Information

Billling Address

Shipping/Service Address

Payment Terms

Trade References

Reference #1

Reference #2

Reference #3

Payment Terms

Authorization