Nelson Labs E1 Customer Profile Form

(Version 2.2 - 26 May 2020)

*Mandatory Field

Parent (Corporate/Headquarters) Information

Name of Parent Company

Bill To Information
Mailing Name*
Address Line 1*
Address Line 2
Address Line 3
Address Line 4
City*
State*
Postal Code*
Country*
A/P Contact Name*
A/P Contact Title/Position*
A/P Telephone*
A/P Inquiries E-mail*
Invoice Delivery E-mail

Contact/Report Information
Same as Bill-To?*
Company Name
Address Line 1
Address Line 2
Address Line 3
Address Line 4
City
State
Postal Code
Country
Contact Name*
Contact Title/Position*
Telephone*
E-mail*

Category Codes
Account Type*
Nelson Sales Rep*
Nelson Account Manager
Geographic Region
Industry Type*
Product Segment*
Customer Segment*
son Labs E1 Customer Profile Form
(Version 2.2 - 26 May 2020)

rmation

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FALSE
FALSE
FALSE
FALSE

Local
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#N/A
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(001) Medical
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Additional Information
Currency*
Language*
PO Required on Invoices
Tax ID #
Tax Exempt ID #
Annual Spend
International Use Only: Hard copy of testing final
report
**Receive hard copy of testing final report in addtion to
electronic report posted to portal (additional charge may apply)

Notes
USD
English
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$25,000.00

No