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Credit Application

Thank you for using LCI Online Credit Application System.  Please proceed by entering the following information then either click SUBMIT or click your browser's print button and fax to 904/241-1220.  One of our staff members, will reply shortly. Please call 904/241-5244 x142 or email rsc@lciltd.com, if you have any additional questions. Thank you for considering LCI, Ltd for your Fluoride needs.
Bill To Information *Required Information
Company Name*:  
Contact Name*: 
Street Address*: PO Box: 
City*: State/Province*: 
Zip/Postal Code: Country: 
Phone Number*: Fax Number: 
Company Type*:
Tax Exempt #: Federal ID #: 
Parent Company: (800): 
HeadQuarters:

Company Principals Responsible for Business Transactions:
Primary Contact*: Title*: Email*:
Secondary Name: Title: Email: 
D&B Number: Purchase Order Required for invoices?

         Trade References
Firm Name* Contact Person* Phone Number* Fax Number* Account Opened?*

Bank Reference Checking Account Number*:
Bank Name*: Branch: 
Contact*: Phone*: 
City*: State*: 
Zip/Postal Code: Country: 
 
I hereby certify that the information in this credit application is correct.   The information included in this credit application is for use by LCI, Ltd. in determining the amount and conditions of credit to be extended.   I understand that LCI, Ltd. may also utilized any other sources of credit which it considers necessary in making this determination.  Further, I hereby authorize the bank and trade references listed in this credit application to release the information necessary to assist LCI, Ltd. in establishing a line of credit.

Terms: Net 30 days from date of shipment. Initial order from new accounts will not be processed unless accompanied by the above requested information.
   
Your Name*: 
Your Email Address*: