New Customer Set up Form

							
																			New Customer Set Up Form
												
							Legal Name of Credit Applicant*:*						

							d/b/a Trade Name(s):						

							Choose terms*:*						
  Net 30 Days
  Credit Card/Cash in Advance

							Requested Credit Amount ($):						
Bill To:

Ship To:

							Same As "Bill To"						

							Attention**						

							Telephone**						

							Attention						

							Telephone						

							Address 1**						

							Address 2						

							Address 1**						

							Address 2						

							City**						

							Zip*						

							State*						

							Fax						

							City**						

							Zip**						

							State**						

							Fax						

							Purchasing Contact Name**						

							Accounts Payable Contact**						

							Purchasing Contact Email**						

							Accounts Payable Email**						

							Purchasing Contact Phone**						

							Accounts Payable Phone**						

							Order Confirmation Email						

							Invoice Email**						

							Business Description**						

							Date Business Started**						

							Federal ID Number**						

							Subsidiary/Division of:						

							Are Purchases Taxable?**						
  Yes
  No
* If no, you must attach sales tax certificate or you will be subject to tax charges.

Corporate Officers, Partners, or Proprietor Information

							Name**						

							Name						

							Name						

							Name						

							Title**						

							Title						

							Title						

							Title						

							Address**						

							Address						

							Address						

							Address						

							Telephone**						

							Telephone						

							Telephone						

							Telephone						

Trade References (Please do not write credit card information)

							Company Name**						

							Contact Name**						

							Address**						

							Telephone**						

							Email**						

							Company Name*						

							Contact*						

							Address*						

							Telephone*						

							Email*						

							Company Name*						

							Contact*						

							Address*						

							Telephone*						

							Email*						

							Company Name						

							Contact						

							Address						

							Telephone						

							Email						
Bank References

							Bank Name**						

							Bank Contact**						

							Bank Account Type**						

							Bank Address**						

							Bank Phone**						

							Bank Email**						

							Bank Name						

							Bank Contact						

							Bank Account Type						

							Bank Address						

							Bank Phone						

							Bank Email						

							Bank Name						

							Bank Contact						

							Bank Account Type						

							Bank Address						

							Bank Phone						

							Bank Email						
Terms and Conditions
CERTIFICATION – The applicant certifies that the information provided in this Credit Application, together with all other information submitted with this Credit Application, is true and correct. Applicant understands that should any information materially change, or at the request of FUJIFILM Irvine Scientific, applicant will update the credit application.

AUTHORIZATION TO RELEASE INFORMATION – All information, which the applicant has certified to be true and correct, included in this Credit Application is for the use of FUJIFILM Irvine Scientific in determining the amount and conditions of commercial business credit to be extended to the applicant. It is not for consumer purposes. I/we hereby authorize all trade and bank references listed in this Credit Application to release all information, verbal or written, to assist FUJIFILM Irvine Scientific in determining the amount and conditions of credit to be extended to the applicant. Furthermore, I/we authorize FUJIFILM Irvine Scientific to utilize any other sources of credit information which it deems reliable in making this determination. Subsequent credit inquiries may be completed by FUJIFILM Irvine Scientific in connection with any update, renewal or extension of credit. FUJIFILM Irvine Scientific reserves the right to terminate credit extension based on their evaluation.
ADDITIONAL SALES TERMS AND CONDITIONS – Standard terms are Net 30 Days. Terms are standard unless otherwise stated on each invoice, or by executed written contract. I/we have read and understand the terms of sale as stated on the front of each invoice, and agree that such terms shall prevail over any other documents issued by purchaser pertaining to the sale of goods, products or services by FUJIFILM Irvine Scientific. All other terms and conditions of sale are expressly disclaimed. I/we agree and understand that all accounts are due and payable according to the terms stated on the invoice. I/we acknowledge that all credit terms are subject to periodic review, and may be modified at the discretion of FUJIFILM Irvine Scientific. I/we understand that FUJIFILM Irvine Scientific may terminate future extensions of credit or may terminate current credit availability at its sole discretion.
I/we agree that in the event credit extended pursuant to this Credit Application is not repaid in accordance with the aforementioned repayment terms, the applicant will reimburse FUJIFILM Irvine Scientific for all collection costs incurred, including reasonable attorney fees and court costs. Should litigation become necessary, I/We agree that the venue shall be in Orange County, State of CA. I/we agree that FUJIFILM Irvine Scientific may assess the applicant service charges and interest at a rate of 1.5 percent per month (18 percent per annum), or the highest rate applicable under the law, on any past due balances.
In the event of any changes in ownership or legal structure of the applicant, I/we agree to notify FUJIFILM Irvine Scientific in writing of these changes by certified mail, mail return receipt requested. FUJIFILM Irvine Scientific shall not be affected by such changes until receipt of this written notification of these changes from the applicant. I/we grant FUJIFILM Irvine Scientific a security interest or lien on all merchandise purchased on the applicant’s account until paid in full.

I/we acknowledge having read and understood the preceding terms and conditions, and certify that the applicant agrees to abide by them.

							I agree to the terms and conditions**						

							Name**						

							Upload Tax Exempt Certificate (if applicable)
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Bill To:

Ship To:

Corporate Officers, Partners, or Proprietor Information

Trade References (Please do not write credit card information)

Bank References

Terms and Conditions
