New Customer Set Up Form

Please fill out information below and click “Submit”
Time to complete: approx. 20 mins

Customer Information

Company Name *
President/CEO Name *
Address *
Address Line 2
City *
State *
Enter your phone number *
Fax Number
Enter your email address *
Tax Exempt Number
Please upload your completed tax-exempt form.
Max file size 10MB.
Upload failed. Max size for files is 10 MB.

Billing Information

Name *
Billing Street Address *
Billing Address Line 2
Billing City *
Billing State *
Billing ZIP Code *

Shipping Information

Shipping Contact Name *
Shipping Contact Phone Number *
Shipping Street Address *
Shipping Address Line 2
Shipping City *
Shipping State *
Shipping ZIP Code *
Shipping Method *
Shipping Account Number
Prepay and add *
Times Open *

Key Contacts

AP Contact

AP Contact Name*
AP Contact Phone Number *
AP Contact Email *

AR Contact

AR Contact Name*
AR Contact Phone Number *
AR Contact Email *

Sales Contact

Sales Contact Name*
Sales Contact Phone Number *
Sales Contact Email *

Technical Contact

Technical Contact Name *
Technical Contact Phone Number *
Technical Contact Email *


Credit Reference A

Credit Reference A Company Name *
Credit Reference A Address *
Credit Reference A City *
Credit Reference A State/ZIP *
Your Account Number with Company A *
Credit Reference A Telephone Number *
Credit Reference A Email or Fax *

Credit Reference B

Credit Reference B Company Name *
Credit Reference B Address *
Credit Reference B City *
Credit Reference B State/ZIP *
Your Account Number with Company B *
Credit Reference B Telephone Number *
Credit Reference B Email or Fax *

Credit Reference C

Credit Reference C Company Name *
Credit Reference C Address *
Credit Reference C City *
Credit Reference C State/ZIP *
Your Account Number with Company C *
Credit Reference C Telephone Number *
Credit Reference C Email or Fax *

General Information

How did you hear about us?
May we contact you by email with a customer review survey?
Best email for review survey:

Customer Authorization

Authorizing Name *
Date of Signature *
I am authorized to make this application and statement to obtain credit from Imperial Carbide, Inc., et al and agree to pay according to the terms of sale as stated on each invoice.

By clicking ‘I Understand’ below you acknowledge that you have read, understand, and agree to be bound by the terms above.
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