New Customer Information Form

New Customer Information

Thanks for your continued interest in Quip Labs! Fill out this form to get set up in our quotes and orders system.

Don't have time to fill out the whole thing right now? Just click "Save and Continue Later" at the bottom of the page and we'll send you a link to pick up right where you left off.

Your Information

Your Name(Required)

Prefix First Last

Your Email(Required)

Company Name(Required)

Phone(Required)

Fax

What Are Your Goals or Objectives?(Required)

Billing

We Would Prefer to Pay By

Credit Card

Purchase Order

Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Bill Attn:

Shipping

Is Shipping Address the Same as Billing?

Yes

Shipping Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Shipping Attn:

I have an existing FedEx Account to bill

Yes. Please bill shipping to my existing FedEx Account

FedEx Account Number

Accounts Payable Contact

Name(Required)

First Last

Phone(Required)

Email(Required)

Fax

Purchasing Contact

Is Purchasing Contact the Same as Accounts Payable?

Yes, purchasing and AP contacts are the same

Name(Required)

First Last

Phone(Required)

Email(Required)

Fax

How would you like to receive notifications?

I Would Like all Notifications Sent to a Single Email Address

Please check to have all your notifications sent to the address below

Email Address for Order Confirmations(Required)

Email Address for Invoice Submission(Required)

Email Address for Shipment Tracking

Tax Exemption

Tax-Exemption Status

Our Organization is not Tax Exempt

Our Organization is Tax Exempt

If Exempt, Please Upload Exemption Letter Here:

Max. file size: 50 MB.

State

Number

Additional Notes

Please Add Any Additional Notes

CAPTCHA

Hidden

Post Tags

Separate tags with commas