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Customer Information Form


PLEASE DIRECT THIS FORM TO YOUR FINANCE DEPARTMENT

To submit your information to Micromeritics, please fill out the form below and click on the Submit button at the bottom of the page. Micromeritics respects your privacy. Please feel free to read our Privacy Policy to learn more about how we protect your personal information. Note that fields that are BOLD are required and must be entered before you can submit the form.

  Submit to: Please check applicable box.

Customer Info

Federal ID #:
DNB #:
NAICS #:
Name for A/P:
Phone for A/P:
Email for A/P:
Purchasing Contact Name
Phone for purchasing:
Email for purchasing:

Billing Details

PLEASE ATTACH YOUR PO OR FAX TO (770) 662-3609 - YOUR ACCOUNT CANNOT BE SETUP WITHOUT A PO
PO #:
Please attach your PO File if applicable
Company Name:
Street Address 1:
Street Address 2:
Street Address 3:
City, State/Province:
Zip +4/Postal Code:
Country:
Contact:
Telephone:

Email for order acknowledgements:
Please attach your Direct Pay Form or Tax Exemption Certificate or fax to (770) 662–3609.