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U.S. Customer Application Form

U.S. Customer Application Form

Thank you for your interest in Restek. To place an order with us, an account for your company must be established in advance. To set up an account, please complete this electronic application. Payments for new accounts will be established as credit card only, unless you also apply for credit terms. If your company wishes to establish credit, you will have the option to do so after submitting this form.

If you have a question about your application or need assistance with an urgent request, please contact Restek Customer Service at csreps@restek.com or call 1-800-356-1688, extension 3.

Fields marked with an asterisk (*) are required.

Company
Company Addresses

Please note that a business address is required; Restek cannot ship to a residential address or P.O. box.

Billing Address





Shipping Address Check box if same as billing address.





Physical Address Check box if same as billing address.





Company Contacts

Bill To



Purchasing Check box if same as "bill to" contact.



Ship To Check box if same as "bill to" contact.



End User Check box if same as "SHIP to" contact.



Default Shipping Information

These selections can be changed for individual orders at the time each order is placed.

Carrier:

Method:



Payment for Shipping: *
#

Tax Status and Required Business Documents

Tax Status *

Acceptable Forms of Documentation

  • Please include a copy of your current business license, state license, DEA registration, or W9.
  • If your business will purchase cannabis standards, submittal of the appropriate business licensing is required.

Please e-mail all documents with your company name in the subject line to Restek’s Customer Service team (csreps@restek.com). We cannot process your application without this information.

Invoicing Options

Payment Options *


Invoice Delivery Preference *


Rewards Program

Are you interested in participating in our Wizard Dollar customer loyalty program? *

Which of the people that you identified in the Company Contacts section above will manage your Restek rewards? *








Type of Business

Do you plan to resell Restek® products? *

Do you plan to export Restek® products? *

If you export Restek® products you must agree to follow our Export Control Notice.

If we have questions about this application whom should we contact?


There are errors in your application.

At Restek, we understand and respect your concerns about the privacy and security of your personal data; for more information, visit www.restek.com/privacy.

Restek Domestic Customer Service

Subject

Message

Your Full Name

Your Email

Company Name

Address

Spam Block (Please leave this blank)

all fields required

Thank you

Your message has been sent. We will be in touch shortly.

Message not sent

Sorry, your message could not be sent at this time. Please try again later, or contact Restek or your local Restek representative via phone.

www.restek.com/Contact-Us