New Client Set-Up FormEMSL Family of Companies

New Client Set-Up Form

EMSL Family of Companies

Please complete the below form if you are seeking to become a new customer with EMSL, LA Testing, or EMSL Canada.

You must be an authorized representative to establish an account with EMSL.

Are you Authorized to establish this account?*

Select

Submission Date*

First and Last Name*

Title*

Email Address*

Phone Number*

Check if you are not the owner of this business.

First and Last Name of Owner*

First and Last Name of Owner *OR* Full Name of Company if a Public Company

Owner Phone Number*

Are you Authorized to approve analytical and product pricing?*

Select or enter value

You answered 'Sometimes' or 'No' Above*

Please include the name and email address of the other employee(s) who have authority to approve analytical and product pricing:

Are you working with an EMSL Representative?*

Select

Name of EMSL Representative*

Please share the name of the EMSL Account Representative you are working with.

Are you submitting samples for a potential or ongoing Lawsuit?*

EMSL requires that you disclose this information to us ahead of sample submission.

Select

Please provide detail regarding the ongoing or potential litigation.*

Billing Information

Accounts Payable First and Last Name*

This is the person/group responsible for paying invoices. 'Accounts Payable' is acceptable if this is a 'Group' and not a person.

Accounts Payable Phone Number*

Phone Number of Person/group responsible for receiving and paying invoices.

Accounts Payable Email Address*

Email of Person/group responsible for receiving and paying invoices.

Analytical Invoice Frequency*

As a standard, EMSL invoices for analytical services with each order. If Monthly or Portal is selected, an additional fee may apply.

Select

Who should receive Analytical Invoices?*

Note - this is separate from the Monthly Statement and Product Invoices.

Select or enter value

First Name, Last Name, and Email of Additional Contacts to Receive Analytical Invoices*

Monthly Statements*

As a default, EMSL will send Monthly statements that include *unpaid* Analytical and Product Invoices, as well as individual Product Invoices, to the Accounts Payable Contact listed here. Should anyone else receive the Monthly Statements and Product Invoices?

Select or enter value

Additional Contacts for Monthly Statements and Product Invoices. First Name, Last Name, Email Address*

If Portal Selected, add Portal System Information*

**There will be an increased fee for EMSL submitting invoices to a portal system.

Please include the following information about your portal or e-Invoice system:

1) Name and phone of person to discuss set-up.

2) Name of the portal or e-invoice system.

3) System registration link

NOTES

*Payment is required for the first set of samples submitted while your account is being established.

**If your company requires a Purchase Order (PO) to process an invoice from EMSL, please contact your Account Manager or info@emsl.com to notify us.

Are you a Tax-Exempt Customer

If you select Yes, EMSL requires a Tax-Exempt Certificate to remove all taxes.

Select

File Upload

Please upload your W-9 here.
If your company is Tax-Exempt, please also attach the certificate.

Drag and drop files here or

Analytical Services / Products

Analytical & Product Services

Please let us know what specific analytical services you are interested in, or which products you are interested in purchasing.

Referral

How did you hear about EMSL?

Select or enter value

Send me a copy of my responses

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Company Information

Billing Information

NOTES

Analytical Services / Products

Referral