1-1. Primary Contact Name *

First Name

Last Name

1-3. Primary Contact Phone *

Country

(###)

###

####

2-1. Billing Contact Name *

First Name

Last Name

2-3. Billing Contact Phone *

Country

(###)

###

####

2-4. Billing Contact Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

3-1. Shipping Contact Name

If the shipping address is different from the billing address, please fill the below.

First Name

Last Name

3-2. Shipping Contact Phone

(###)

###

####

I agree to authorize FixUp Biochemical to ship on my behalf.

5-3. Authorization for Credit Check - If the Credit Limit Requested exceeds $2,500

*By checking this box, I authorize FIXUP BIOCHEMICAL INC. to access my/belonging company's credit report to evaluate my application. I understand this may affect the credit score and will be handled according to applicable laws.

I agree to the terms and authorize the credit check.

Authorization *

"I confirm that I am authorized to set up accounts on behalf of my organization and that the information provided above is accurate and complete."