To be eligible for credit review, please fill out the form below in its entirety. Fields with asterisks(*) are required.

Organization Information
Name of Organization*
Organization Type*
Please specify your organization type.*
Address*
City*
State*
Zip Code*
Accounts Payable Information
Contact First Name*
Contact Last Name*
Email Address*
Phone*
Fax*
Account Requirements
Does your account have special billing requirements?*  Yes    No
Please explain your billing requirements.*
Are you claiming exemption from state or local sales tax?*
(Sales tax will be collected if exemption certificate is not received.)
Please attach or fax a copy of your state tax exemption certificate to: (866)-935-3829
 Yes    No
Find your sales tax exempt certificate here
Find your certificate by state at the link above, download the PDF form to your computer, then click "Choose File" to upload the certificate with this form.
Attach your tax exempt certificate here.*

Are you requesting an open account with credit terms?*  Yes    No

FOR CREDIT TERMS: Please provide trade references and bank information. All fields are required.

Trade Reference One(1)
Company Name*
Address*
City*
State*
Zip Code*
Phone Number*
Fax Number*
Email Address*
Trade Reference Two(2)
Company Name*
Address*
City*
State*
Zip Code*
Phone Number*
Fax Number*
Email Address*
Requestor Information
First Name*
Last Name*
Title*
Email Address*
Phone Number*
By submitting this application, I declare that I am an authorized representative of my organization.*

Customer Support: If you require assistance with this form, please contact customer support.

Phone: 877-LAERDAL (523-7325)
Email: credit@laerdal.com
Customer Service Fax: (845) 298-4556

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