Customer Questionnaire

Customer Questionnaire
Welcome to the AquaPhoenix family! Please take a moment to fill out our Customer Questionnaire. We tried to make it as painless as possible. This form captures all the information needed to set you up with an account. We will use this information to design your product labels, ship items to the right place, and get in touch with the right people. Contact us at (866) 632-1291 with any questions.

Hey Educators – head over here to get started with AquaPhoenix Education.
1. Company Information
Company Name *
DBA
Company Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Company Phone Number *
Company Website
2. Contact Information
Billing - Accounts Payable
Billing Contact Name *
Billing Contact Title *
Billing Address is the same as Company Address
Invoicing Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Billing Contact Phone Number *
Please enter a valid phone number.
Ext.
Billing Contact Email *
Invoicing Email *
Preferred Delivery Method *

Email Direct Mail
If applicable, please provide us with a current W9 and all applicable sales tax exemption documentation.

Cancel of
TERMS: Our standard terms are Net 30 for approved accounts. If you prefer, we can process payments at time of shipping using Visa, MasterCard, Discover, or American Express. Please call the accounting department at 1-866-632-1291 to provide your credit card information.
Purchasing
Purchasing Contact Name *
Purchasing Contact Title *
Purchasing Address is the same as Company Address
Purchasing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Purchasing Phone Number *
Please enter a valid phone number.
Ext.
Purchasing Email *
Sales Order Acknowledgement Email *
Additional Contact
Would you like to add an additional contact? *

Yes No
Additional Contact Name
Additional Contact Title
Additional Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Additional Phone Number
Please enter a valid phone number.
Ext.
Additional Email
3. Private Labeling
Would you like your AquaPhoenix Manufactured reagents private labeled? *

Yes No
If YES:

Type the contact information that you would like to appear on your labels in the boxes below. This will default to AquaPhoenix contact information if left blank. This information is mandatory. Due to OSHA/GHS label requirements, P.O. boxes are not acceptable.
Company Name for Private Labeling
Address for Private Labeling

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Business Phone Number for Private Labeling
Please enter a valid phone number.
Hazardous Chemical Emergency Phone Number
Please enter a valid phone number.
Follow the logo requirements below for sending us your company logo. It's important that you provide us with a high-quality logo so that we can provide you with a printed product that you are proud to display.

Logo Requirements
- Logos should be minimum of 300dpi.
- Acceptable formats include JPEG, PSD, and EPS.
- DO NOT send logos that are in Word, Excel or Powerpoint.
File Upload

Cancel of
Example of a logo printed on a label:

We will email you a proof of your label for approval.
4. Shipping Information
Do you prefer that we ship Prepay and Add or Freight Collect? *

Prepay and Add Freight Collect
If freight collect:
Small and Large Carrier

FedEx UPS
Second Carrier for Large Freight
Small Carrier Account Number
LTL Billing Address
LTL Billing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Additional Information
What else should we know to best serve your needs?
Should be Empty:

Contact Us

Customer Questionnaire

1. Company Information

2. Contact Information

Billing - Accounts Payable

Purchasing

Additional Contact

3. Private Labeling

4. Shipping Information

If freight collect:

LTL Billing Address

Additional Information