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eTACONIC

Taconic
Customer Service
New Customer Application

New Customer Application

This form is to be completed by companies/institutions who wish to purchase products and services from Taconic Biosciences. There are three major components: company/institution information, shipping information, and billing information. All required fields are marked with a red asterisk *

Company or Institution Information

Company or Institution Name *

Company or Institution is required and cannot be empty.

Country *

Country is required and cannot be empty.

Address Line 1 *

Address is required and cannot be empty.

Address Line 2

City *

City is required and cannot be empty.

County/Region/Province

County is required and cannot be empty.

State *

State is required and cannot be empty.

Postal Code *

Postal Code is required and cannot be empty.

Type of Business *

Type of Business is required.

Currency *

Financial Classification *

European Union VAT# *

VAT is required for European Union countries.

*Mandatory for EU customers. If not provided, full rate will be used

Contact First Name *

First Name is required and cannot be empty.

Contact Last Name *

Last Name is required and cannot be empty.

Title *

Title is required and cannot be empty.

Email *

Email is not properly formed.

Phone Number *

Numbers, dashes or spaces only please.

Fax

Numbers, dashes or spaces only please.

Preferred Method of Contact: *

Email

Fax

Telephone

Please select confirmation by.

Preferred Customer Service Location: *

US

EU

CN

Shipping Address Information

Is the Shipping information the same as the Company/Institution information?

Company or Institution *

Company or Institution is required and cannot be empty.

Country *

Please select a Country.

Address Line 1 *

Address is required and cannot be empty.

Address Line 2

City *

City is required and cannot be empty.

County/Region/Province

County is required and cannot be empty.

State *

State is required and cannot be empty.

Postal Code *

Shipping Contact First Name *

First Name is required and cannot be empty.

Shipping Contact Last Name *

Last Name is required and cannot be empty.

Contact Title

Shipping Contact Email *

Email is not properly formed.

Shipping Contact Phone Number *

Numbers, dashes or spaces only please.

Shipping Contact Fax

Numbers, dashes or spaces only please.

Preferred Time of Delivery *

Special Delivery Instructions

Add an additional shipping contact? +-

Company or Institution

Company or Institution is required and cannot be empty.

Country

Please select a Country.

Address Line 1

Address is required and cannot be empty.

Address Line 2

City

City is required and cannot be empty.

County/Region/Province

State

State is required and cannot be empty.

Postal Code

Shipping Contact First Name

First Name is required and cannot be empty.

Shipping Contact Last Name

Last Name is required and cannot be empty.

Shipping Contact Email

Email is not properly formed.

Shipping Contact Phone Number

Numbers, dashes or spaces only please.

Shipping Contact Fax

Numbers, dashes or spaces only please.

Billing Address Information

Is the Billing information the same as the Shipping information?

Is the Billing information the same as the Company/Institution information?

Company or Institution *

Company or Institution is required and cannot be empty.

Country *

Please select a Country

Address Line 1 *

Address is required and cannot be empty.

Address Line 2

City *

City is required and cannot be empty.

County/Region/Province

County is required and cannot be empty.

State *

State is required and cannot be empty.

Postal Code *

Billing Contact First Name *

First Name is required and cannot be empty.

Billing Contact Last Name *

Last Name is required and cannot be empty.

Contact Title

Billing Contact Email *

Email is not properly formed.

Billing Contact Phone Number *

Numbers, dashes or spaces only please.

Billing Contact Fax

Scandinavian EAN# *

Annual Estimated Purchasing $/€ *

Amount is required and cannot be empty.

Tax Exempt (US Only):

Yes

No

(If yes, please provide document as a pdf, txt, or doc file no greater than 5mb in size)

Invoice Distribution Method: *

Mail

Email

Please provide invoice email address: *

Email is not properly formed.

***Payment terms will be confirmed following review by Taconic's Finance Team***

Taconic needs the contact information you provide in this form to respond to your request.
For details please see our Privacy Policy.

Customs Broker Information

First Name *

First Name is required and cannot be empty.

Last Name *

Last Name is required and cannot be empty.

Address Line 1 *

Address is required and cannot be empty.

Address Line 2

City *

City is required and cannot be empty.

Province *

Province is required and cannot be empty.

Postal Code *

Postal Code is required and cannot be empty.

Contact First Name *

First Name is required and cannot be empty.

Contact Last Name *

Last Name is required and cannot be empty.

Contact Phone Number *

Numbers, dashes or spaces only please.

Contact Fax

Contact Email *

The email is required and cannot be empty.

Comments

All of your information has been submitted to Taconic Biosciences.
If you need to make a revision press "Edit".

Otherwise press "OK" to return to the Start an Order page.

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