Customer Account Setup

NOTE: If you wish, you can download the same questions in a PDF document and email it back to us at the email stated at the bottom of the form.

Customer Account Setup (FRM.CR.051)

"*" indicates required fields

Main Contact Information

Institution/Company Name*

Department*

Primary Contact Name*

Telephone*

Email*

Purchasing/Buyer Name*

Telephone*

Email*

Accounts Payable Contact (optional):

Telephone

Technical/Lab Contact (optional):

Telephone

Certifications (optional):

VAT Tax Number

FEIN Number

Lab Permit Number

Sales Tax Exemption Number (email certificate to sales@anshlabs.com)

Shipping Address Details:

Institution/Company*

Attention to*

Telephone*

Email*

Shipping Address

Street Address 1 * Street Address 2 * City * State * Zip / Postal Code* Country *

Special Receiving Instructions

Billing Address Details:

Is the Billing Address different from the Shipping Address?

Institution/Company

Attention to

Billing Address

Street Address 1 Street Address 2 City State ZIP / Postal Code Country

ALL UNITED STATES ACCOUNTS

TAX EXEMPTIONS: Is your organization tax exempt?

If Yes, please email your certificate to mailto:sales@anshlabs.com

If No, your organization agrees that any applicable sales/use tax for purchases made from Ansh Labs, LLC, will be the responsibility of your institution. You confirm that all sales/use tax payments have been or will be made directly by your institution to your state.

Confirmation Signature (Type In):*

Date*

ALL INTERNATIONAL ACCOUNTS:

TRADE SANCTIONS:

Ansh Labs products shall not be distributed or shipped to countries where there are trade sanctions as determined by the United States Department of the Treasury. These countries include Cuba, Iran, North Korea, and Syria (not an exhaustive list).

By signing (typing your name) below, you confirm on behalf of yourself and your institution that our products will not be exported to sanctioned countries.

Confirmation Signature (Type In)*

Date*

FOREIGN CORRUPT PRACTICES ACT:

Your organization agrees not to offer, pay, or provide anything of value to foreign officials or customers with the intent to improperly influence any business-related outcomes, including product registration or market share expansion, in violation of applicable laws.

Confirmation Signature (Type In)*

Date*

INTERNATIONAL DISTRIBUTOR ACCOUNTS ONLY:

COMMITMENT TO RECORD KEEPING:

As a distributor of Ansh Labs’ products, we agree to maintain the following records:

1. History of all customers who have received Ansh products. This history shall include all customer contact details, and information corresponding to product(s) received. It should include part numbers (including dates and quantities of each Ansh product shipped along with corresponding catalog numbers and lot numbers).

2. Records of any reported problems relating to the performance characteristics or safety of a product, including any user complaints, received after it was first sold.

Confirmation Signature (Type In)*

Date*

Customer Account Setup Form
Document No: FRM.CR.051, Revision No: 05, Release Date: 08/30/2024