Energy Labs - Customer Profile

Please fill out the form below in its entirety and click SUBMIT at the bottom once all required information is filled in.

General Information

Company Name*

Company Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address*

Same as Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Fax

Accounts Payable Information

Contact Name*

Contact Address*

Same as Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

How would you like to receive invoices?*

Hard Copy
Email

Email

How would you like to receive statements?*

Hard Copy
Email

Email

How would you like to receive reports?*

Hard Copy
Email

Email

Invoices are required to have a Purchase Order?*

Yes
No

Primary PO Contact

PO Contact Phone Number

Additional Billing Requirements or Comments

If AP is responsible for other locations/subsidiaries, please attach a separate sheet with information for each including: Company Name, Contact, Mailing Address, City, State, Zip and Telephone. *Payment terms are Net 30*

Business Information

Type of Entity*

Corporation
Partnership
Sole Proprietorship
Government

Federal ID#

Principal Owners or Corporate Officers

Primary Owner or Officer*

Name Title

Additional Owners or Officers

Name Title

Additional Owners or Officers

Name Title

Additional Owners or Officers

Name Title

Account Code*

ELI #

Name

This field is for validation purposes and should be left unchanged.