Customer Application Form

Thank you for completing this Customer Application! Once your company information is set-up in our system, you will have the ability to purchase any of our high quality supplies and consumables.

If you'd like to enjoy the benefits of certifying your Pre-Owned Santinelli Lens Edger, call us to find out how: 800.644.3343 ext. 359.

Santinelli International Customer Application Form

*Required Fields

Bill To:

Company Name/DBA*

Street Address*

City*

State*

Zip*

Tel # *

Fax #

Primary Owner First Name*

Primary Owner Last Name*

Email*

Accounting Info:

Same Contact Info As Owner?*

Accounting Contact First Name

Accounting Contact Last Name

Accounting Contact Email

Tax ID #

Ship To:

Same Information as Bill To?*

Company Name

Ship Street Address

Ship To City

Ship To State

Ship To Zip

Ship To Tel #

Ship To Fax #

Operator Info:

Same Information As Owner?*

Operator First Name

Operator Last Name

Operator Email

Equipment Info:

Model

Serial # * Terms & Conditions: I represent that I have the authority to execute this account summary on behalf of my organization. I further acknowledge that I am aware of the following: Until the equipment is certified by a Santinelli Representative Technical, phone support is billable at $125 per incident. If during that call it is determined that on-site service is needed to resolve your issue, the phone support fee will be put towards the future on-site service charges. Payment is required in advance for all phone support, parts orders and travel fees related to onsite service. Parts are non-returnable unless equipment has been certified. For more information on the benefits of certifying your pre-owned edger please go to www.santinelli.com/certification.

I agree to the above terms and conditions *

First Name*

Last Name*

Title

Date Date