Chinchilla Life Sciences Net 30 Application

Contact Name *

Contact Email *

Legal Business Name *

Have you received a Formal Quote from us?

Yes

No

Product You are Interested in Purchasing *

Please type the product make and model, or paste the URL of the product you are interested in purchasing.

Phone Number *

Company Billing Address *

Commercial Shipping Address *

Accounts Payable Contact *

Accounts Payable Phone Number *

Accounts Payable Email Address *

Federal ID# *

Company Website URL *

Terms Requested *

Net 30

Other

How will you pay for the invoice on the due date? *

Company Check

ACH/ETF/Wire

Credit Card

Are you a Subsidiary or a Division of a Parent Company? * *

Yes

No

By Checking This Box, You Agree to Chinchilla's Terms and Conditions.