Carolina Liquid Chemistries- Credit Application

Credit Application

We request new customers complete the information below.

Company Name
Address
Street Address City State ZIP Code
Contact
First Last
Phone
Fax
Email
Enter Email Confirm Email
Date business commenced
Type of Business
- Sole proprietorship
- Partnership
- Corporation
- Other
Business and Credit Information
Address
Street Address City State ZIP Code
How long at current address?
Phone
Email
Enter Email Confirm Email
Bank Name
Address
Street Address City State ZIP Code
Savings Account #
Checking Account #
Other
FED Tax ID # / SS #
Business/Trade References
Company name
Address
Street Address City State ZIP Code
Phone
Email
Enter Email Confirm Email
Type of account
Company name
Address
Street Address City State ZIP Code
Phone
Email
Enter Email Confirm Email
Type of account
Company name
Phone
Address
Street Address City State ZIP Code
Email
Enter Email Confirm Email
Type of account
Agreement
By selecting the "Submit" button, you are signing this Agreement electronically, and you are authorizing Carolina Liquid Chemistries Corp. to make inquiries into the banking and business/trade references that you have supplied
Authorized Signature
Printed Name
Title
Date
MM
DD
YYYY
Authorized Signature
Printed Name
Title
Date
MM
DD
YYYY

Carolina Liquid Chemistries delivers quality products and exceptional service for reference and clinical laboratories throughout the United States.

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Statement on “Forensic Use Only” Products
Forensic Use Only devices are intended for use only in drugs of abuse testing for law enforcement purposes. Appropriate users of such devices include, for example, court systems, police departments, probation/parole offices, juvenile detention centers, prisons, jails, correction centers and other similar law enforcement entities, or laboratories or other establishments performing forensic testing for these entities. Forensic Use Only devices are not designed, tested, developed, or labeled for use in other settings, such as clinical diagnostic or workplace settings. CLC does not market or sell these devices for any use other than Forensic Use. These devices do not have FDA clearance for clinical uses. By purchasing these products from CLC you are certifying that you are using them for Forensic Use Only.

Credit Application

Business and Credit Information

Business/Trade References

Agreement