Request for Company/Ownership Information

Date:
Company Name:
Company Address:
Compnay Phone:
Company Fax:
Company EIN/GST/VAT Number:
Email:
Owner Name(s):
Bank Affiliation:
Bank Contact:
Bank Phone:
Bank Fax:
Accounts Payable Contact:
Accounts Payable Phone:
Accounts Payable Fax:
Accounts Payable Email:
Import Department Contact:
Import Department Phone:
Import Department Fax:
Import Department Email:
Shipping Address (if different from above):

In order for your company to purchase merchandise from Research Concepts, Inc., you must submit a signed, numbered purchase order. This must include company name and address as well as the shipping information for the ultimate consignee. PLEASE NOTE THAT WE WILL SHIP ONLY TO THE ULTIMATE CONSIGNEE. Upon transfer of funds for completion of your order, your company agrees to all rules and regulations prohibiting sale, transport, and distribution of RCI products to embargoed entities (countries, companies, and/or individuals) as stated by the United States Department of Commerce, Bureau of Export Administration.