Charm Sciences Customer Application Form

SHIP TO

Company Name(Required)

Address(Required)

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

Shipping Contact Name(Required)

First Last

Shipping Contact Email(Required)

Shipping Contact Phone(Required)

BILL TO

Company Name(Required)

Address(Required)

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

Billing Contact(Required)

First Last

Billing Email(Required)

Billing Phone Number(Required)

D&B Number

Nature of Business

Years in Business

TAX EXEMPT

The sales/use tax obligation is the customers. Please provide the applicable Tax Exempt Certificate. If no certificate is provided, sales tax might be collected and will not be refunded.

Tax Exempt(Required)

Yes

Tax Exempt Certificate(Required)

Max. file size: 128 MB.

Purchase Order Numbers(Required)

Please indicate if your company requires purchase order numbers: *

Yes

TERMS NET 30 DAYS PENDING REVIEW OF D&B. All invoices will be sent via email. Please add sladmin@charm.com or *@charm.com to your company’s white list.