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. Click here to download a PDF version of the Customer Questionnaire and Private Label Guide.

1. Company Information

* Company Name:

DBA:

* Address Line 1:

Address Line 2:

* City:

* ZIP/Postal:

Country:

* State/Province/Region:

* Phone:

Website Address:

2. Contact Information

Billing - Accounts Payable

* First Name:

* Last Name:

Title:

* Invoicing Mailing Address:

* City:

* ZIP/Postal:

Country:

* State/Province/Region:

* Phone:

Ext:

* Contact Email:

* Invoicing Email:

* Preferred Delivery Method:
EmailDirect Mail

** If applicable, please provide us with a copy of your sales tax exemption certificate.

TERMS: Our Standard terms are Net 30 for approved accounts. If you prefer, we can process payments at the 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

* First Name:

* Last Name:

Title:

Purchasing address is the same as billing address.

Address:

City:

Country:

ZIP/Postal:

State/Province/Region:

* Phone:

Ext:

Email Address:

Sales Order Acknowledgement Email:

Additional Contact

First Name:

Last Name:

Title:

Address:

City:

ZIP/Postal:

Country:

State/Province/Region:

Phone:

Ext:

Email Address:

3. Private Labeling

Would you like your AquaPhoenix manufactured reagents private labeled? YesNo

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:

Address:

City:

ZIP/Postal:

Country:

State/Province/Region:

Business Phone:

Hazardous Chemical Emergency Phone:

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.

Logo Upload:

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 AddFreight Collect

If freight collect:

Small and Large Carrier:

Second Carrier for Large Freight:

Small Carrier Account Number:

LTL Billing Address:

Mailing Address:

City:

ZIP/Postal:

Country:

State/Province/Region:

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:

5. Additional Information