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Credit Application

 For your protection, this form is secure

Before submitting this application, please download our credit terms acknowledgement letter**.

Please complete this online form and click submit. Or, print and fax the form to (352) 237-0239, Attn: Credit/Collections Department. You may also email the form to usaar@usascientific.com.

**Please note: this form is required for the credit application process. When listing references, please include companies you purchase products or supplies from. (Fisher Scientific and VWR do not provide trade references.)**

* denotes required field

General Information*
Company Legal Name
Business Address
Business City
Business State
Business Zip Code
Main Office Phone Number
Main Office Fax Number
Email Address
Shipping Address
Shipping City
Shipping State
Shipping Zip Code
Billing Address
Billing City
Billing State
Billing Zip Code
Financial Information*
Federal Tax I.D #
State Tax I.D #
Date Business Commenced
Tax Exempt Status (Yes or No) Fax your Tax Exempt Certificate to 352-237-0239
Tax Exempt #
Please list any company aliases
Please list any affiliated businesses
Primary Business Contact Name
Primary Business Contact Phone
Primary Business Email Address
Secondary Business Contact Name
Secondary Business Contact Phone #
Secondary Business Contact Email Address
Accounts Payable Contact Name
Accounts Payable Contact Phone #
Accounts Payable Contact Email Address
Trade Reference #1 *
Company Name
Contact Person
Address
City
State
Zip Code
Account #
Telephone Number
Fax Number
Email Address
Trade Reference #2*
Company Name
Contact Person
Address
City
State
Zip Code
Account #
Telephone Number
Fax Number
Email Address
Trade Reference #3*
Company Name
Contact Person
Address
City
State
Zip Code
Account #
Telephone Number
Fax Number
Email Address
Additional Information
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