CENTURY LABS II CORPORATION

Customer Information Sheet

Please fill out the new customer form below. We will contact you shortly.

For our fax form version, click here.

Fields with an * are required.

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Company Name: *
Email Address: *
Full Mailing Address: *
Full Shipping Address: *
Full Billing Address: *
Reminder Notice (name and address) *
Who do we contact when your equipment is coming due for calibration? *
To whom should we send your calibration certificate?
Contact Name:
Contact Title:
Contact Phone:
Contact Fax:
Contact Email:
BILLING INFORMATION
Billing Name: *
Billing Title:
Billing Phone: *
Billing Fax:
Billing Email:
TECHNICAL INFORMATION
Technical Name:
Technical Title:
Technical Phone: *
Technical Fax:
Technical Email:
PURCHASE ORDER INFORMATION
P.O. Name:
P.O. Title:
P.O. Phone:
P.O. Fax:
P.O. Email:
PAYMENT INFORMATION
Payment Terms: *
State Tax Exempt #:
Data Required: *	Yes No Only if found out of tolerance
Your Quality Certification/Accreditation:
Do you require/desire ISO 17025 Accredited Calibration? *
Calibration Interval (In months) *
Due Date Adjustment (ex. End of Month)?
Purchase Order Required? *	Yes No
Shipping Preference:
Account Number (if we are to use)
How did you find us?

form mail