Customer Information Form Kurt J Lesker Company

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Customer Information Form
Kurt J Lesker Co
Remit To:
Shipping Address:
Mailing Address:
PO BOX 515
553 Basaltic Rd
553 Basaltic Rd
31 Adelaide Street East
Concord, ON L4K 4W8
Concord, ON L4K 4W8
Toronto, ON M5C 2J6
Phone: 800.465.2610
Federal Tax ID: 136275914
Federal Cage Code: 29145
1) Mailing & Remittance Addresses
Mailing Address
Remittance Address (if different)
Company Name:
__________________________________
__________________________________
__________________________________
__________________________________
Address:
__________________________________
__________________________________
__________________________________
__________________________________
City:
__________________________________
__________________________________
State/Province:
__________________________________
__________________________________
Country
__________________________________
__________________________________
Zip Code/Postal Code:
__________________________________
__________________________________
Phone Number:
__________________________________
__________________________________
FAX Number:
__________________________________
__________________________________
Email Address:
__________________________________
Website: __________________________
Payment Terms Requested:
Other __________________
CC
N30
COD
CIA
C-AD
2) Shipping & Tax Information
Freight Carrier Preference:_________________________________
Collect? If yes, #:____________________
Tax Information:
Taxable
Non-Taxable (if non-taxable, please attach certificate)
Export
2) Company Information
Company Type:
OEM
Industrial
University
Government
Other ____________________
Business Segment:
R&D
Thin Films
Other Vacuum
Other (Please specify) _________________
Main Sales Contact:
Main Accounts Payable Contact:
Name: ____________________________
Name: ____________________________
Title:
____________________________
Title:
____________________________
Email: ____________________________
Phone: ____________________________
Phone: ____________________________
Email: ____________________________
3) Other
Country of ultimate use for products purchased from Kurt J Lesker Company *_______________________
(*If other than USA, please fill out attached form SAF-222)
Literature Requested:
Catalog
Lesker Tech Subscription
Literature (specify)______________________
PAGE 1 of 1
SAF-206V4.0 7-Oct-2015

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