Customer Account Setup

NOTE: If you wish, you can download the same questions in a Microsoft Word 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 INTERNATIONAL ACCOUNTS:

TRADE SANCTIONS:

Ansh Labs strongly believes in ensuring that our products do not end up in countries where there are trade sanctions as determined by the United States Department of the Treasury. If you plan to re-export any Ansh Labs products to any of the countries on the following lists, please first contact Ansh Labs to find out if any special licenses are required or if certain entities, governmental or persons, are illegal to trade with. These countries include Cuba, Iran, North Korea, and Syria (not an exhaustive list).

By signing (typing your name) below, I confirm on behalf of myself and my institution that we will not export products to these countries:

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: 04, Release Date: 06/30/2023