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This form
is intended only for Scale Dealers, OEM and Scales Service Companies.
End users will be discarded or re-directed to a distributor in their
area.
* Required
information
Company
Information*
Company Name:
Contact Name:
Street Address:
City:
State/Province:
Zip Code:
Country:
Phone:
Fax:
E-Mail:
Years in Business:
Business Status*
Type of Business*
Corporation
Manufacturer
Manufacturer
Dealer
Individual
Service
Name of Officers, Owner or Partners*
President:
Vice President:
Secretary:
Treasurer:
Owners:
Partner:
Bank Reference*
Bank Name:
Street Address:
City:
State/Province:
Zip Code:
Country:
Bank Phone:
Bank Fax:
Account Number:
Business References*
At least one reference must be given
Reference 1*
Reference
2
Reference 3
Full Name:
Street Address:
City:
State/Province:
Zip Code:
Country:
Phone:
Fax:
Full Name:
Street Address:
City:
State/Province:
Zip Code:
Country:
Phone:
Fax:
Full Name:
Street Address:
City:
State/Province:
Zip Code:
Country:
Phone:
Fax:
Tax Exempt Number:
*Note: Terms are Net 30 days, 1.5% per month finance
Charge on unpaid balance after 30 days. 18% annual rate.
If account is sent to a collection agency, a 25% service
charge for collection will be added.
I Agree (type your name)
Title:
Date:
Enter Validation Code To Continue
To prevent spamming, please enter in the letters in the box.