SHIP TO ADDRESS : BILL TO ADDRESS : (if different than ship to address)
line 1) ______________________________________ line 1) ______________________________
line 2) ______________________________________ line 2) ______________________________
line 3) ______________________________________ line 3) ______________________________
line 4) ______________________________________ line 4) ______________________________
line 5) ______________________________________ line 5) ______________________________
Standing Purchase Order No.) ______________________________
Physical Address (if PO Box given in Ship To Address) __________________________________
_______________________________________________________________________________
Company Owner: ________________________________________ Phone: __________________
E-mail address: _________________________________________
Social Security No. or Federal TIN No. : ________________________________
Radiation Safety Officer: __________________________________ Phone:
__________________
E-mail address: __________________________________________
Radiation Control License/Registration No.: _____________________________
Please list NAMES, COMPLETE ADDRESSES AND PHONE NUMBERS of three main SUPPLIERS and your PRINCIPAL BANK:
SUPPLIERS NAME:_______________________________________________________________
ADDRESS:_______________________________________________________________________
CITY:__________________________________STATE:___________________ZIP____________
PHONE NO: ________________________________FACSIMILE NO._______________________
SUPPLIERS NAME:_______________________________________________________________
ADDRESS:_______________________________________________________________________
CITY:__________________________________STATE:___________________ZIP____________
PHONE NO: ________________________________FACSIMILE NO._______________________
SUPPLIERS NAME:_______________________________________________________________
ADDRESS:_______________________________________________________________________
CITY:__________________________________STATE:___________________ZIP____________
PHONE NO: ________________________________FACSIMILE NO._______________________
BANK NAME:____________________________________________________________________
ADDRESS:_______________________________________________________________________
CITY:__________________________________STATE:___________________ZIP____________
PHONE NO: ________________________________FACSIMILE NO._______________________
ACCOUNT NO:___________________________________________________________________
SPECIFIC AEIL SERVICE REQUESTED:
(Check all that apply and
complete the order form specific to the checked services.)
Personnel Monitoring Service: ( )
Leak/Wipe Testing Service: ( )
Radiaiton Survey Meter Calibration Service: ( )
Remember to return this General Application form along with the completed SPECIFIC AEIL SERVICE REQUESTED form(s). Also, remember to enclose either your company purchase order or a check in the amount of $75.00 which is applied as a credit balance toward your account. Minimum service contract is $75.00. All new or reactivated accounts are assessed a $15.00 setup fee. Billing consist of Quarterly itemized invoices/statements. Terms net 30 days.
*** Note : By signing this application the signer agrees to all account requirements and pricing terms set forth by Atomic Energy Industrial Laboratories of the SW, Inc.
Authorized Signature: ____________________________________ Date:
___________________
Printed Name: __________________________________________ Title:____________________