New Account Set Up Form Account Set-Up Form Thank you for chossing Chemtek, Inc.! We consider it a privilege that you have given us the opportunity to earn your business! Please fill out the Account Set Up Form Below. The information you provide will help us establish your company on an open account basis. Date(required) Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Month January February March April May June July August September October November December Year Year 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Company/Municipality Name(required) Your Name(required) Your Email Address(required) (This email address will be used for confirmation of form submittal) Billing Contact Information I will accept invoices by the following methods(required) Email Fax US Mail Email address (for invoice)(required) Fax (for invoice) Billing/Mailing Address (for invoice)(required) Accounts Payable Contact(required) Accounts Payable Contact Phone(required) Accounts Payable Fax Accounts Payable Email(required) General Business Information Federal Tax ID Number Are you sales tax exempt?(required) Yes No Sales Tax Exemption Number(required) Please Upload Sales Tax Exemption Form(required) Browse... Maximum size 10MB Please Upload W9(required) Browse... Maximum size 10MB Ordering Information Purchasing Agent: Purchasing Agent Phone Number: Purchasing Agent Email Address (For order/shipping confirmation) Are purchase orders required? (required) Yes No Agreement & Signature AGREEMENT All accounts are COD until an account set up form has been submitted and approved. If any indebtedness incurred pursuant to this request for credit is not paid when due, the undersigned agrees to pay all costs of collection, including reasonable attorney's fees. Any balance so remaining unpaid shall bear interest at the lesser rate of 1.5% per month or the maximum rate permitted by applicable law, until paid in full. ACCEPTANCE AND APPROVAL(required) I accept the terms and conditions set forth herein. Electronic Signature(required) Typing your electronic signature authorizes CHEMTEK, INC., to make any and all inquiries necessary to process this Credit Application Title of Authorized Representative:(required) Type the characters(required) This field should be left blank Send Please wait...
