225 County Road, Tenafly 
NJ 07670-1818
Tel: 201-569-5001
Fax: 201-569-4666 
E-mail: lily@vicorind.com
 
Please provide the following information to enable us to set up your account.
Our delivery term is FOB Tenafly, NJ and payment term is NET 30 days (upon credit approval)
Bill To Address:
Company Name
Address
City State: 
Country Zip Code:
TAX ID / VAT #
 
Ship To Address:
Company Name
Address
City State:  
Country Zip Code:
  
Freight Forwarder:
Name:
Tel:
Fed-EX account #
DHL account #
UPS account #
Other courier Name: Account Num:
Insure Shipment (Check for yes)
Head of Purchasing Dept:
Name:
Tel: Fax: 
Email:
 
List of Authroized Buyers
Name: Tel: 
Name: Tel:
Name: Tel:
 
Accountant / Controller:
Name:
Tel: Fax:
Email:
 
Account Payable Clerk:
Name:
Tel: Fax:
Email
 
3 Trade references:
Name:
Address:
Tel: Fax:
Contact Person:
Name:
Address:
Tel: Fax:
Contact Person:
Name:
Address:
Tel: Fax:
Contact Person:
This form was sent by (Name) Date:
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