Laerdal Credit Setup Form

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