Laboratory Disposable Products, Inc.

The undersigned is applying for credit with LDP and agrees to abide by the terms and conditions of the company’s standard contract.

:: Company Name and Address

Company Name *

Address 1 *

Address 2

Address 3

City *

State *

Zip *

Phone *

- -

Fax

- -

Email *

Federal Tax ID or Social Security No. *

Type of Business *

No. of Employees *

Date Business Established *

Types of Products You Will Purchase *

Amount of Credit Requested *

Check which is applicable to you? *

Corporation	Sole Proprietorship
LLC	Limited Partnership
General Partnership	Others
If others, please specify:

State where your company was organized *

Have you or any of your affiliates ever had credit with us before or purchased from us before? *

Yes No

If yes, under what name?

:: Name or title of persons authorized to act on your behalf

First Name *

Last Name *

Title *

Trade References *

:: Reference #1 Name and Address

First Name *

Last Name *

Phone: *

- -

Address1 *

Address2

City *

State *

Zip *

:: Reference #2 Name and Address

First Name

Last Name

Phone

- -

Address1

Address2

City

State

Zip