Customer Account Setup Form (Rtech Transfer)
This information will help Mérieux NutriSciences meet your requirements and is required prior to processing your first sample. This form will take approximately 10-20 minutes to complete and must be submitted and completed in its entirety.
Section 1: Company Information
Company Name*
Primary Location Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Primary Location Type*
Primary Location Phone Number*
Area Code Phone Number
Primary Location Alternate Phone Number
Area Code Phone Number
Primary Location Fax Number
Area Code Phone Number
Do you have the ability to submit your Sample Analysis Request Form electronically?*
Yes No
List of Sales Emails
Reply Email to Sales
Name of Sender for Sales Confirmation Emails
Phone Number
Area Code Phone Number

Section 2: Primary Account Contact
This contact receives the Certificate of Analysis (COA)
Full Name*
Prefix First Name Middle Name/Intl. Last Name Suffix
Does the Primary Contact have the same Company Name?*
Yes No
Primary Contact's Company Name*
Job Title*
Job Department
Does the Primary Contact have the same address as the Primary Location Address?*
Yes No
Primary Contact's Location Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Does the Primary Contact have the same Primary Number as the Company Phone Number?*
Yes No
Primary Phone Number*
Area Code Phone Number
Is the Primary Number also the Primary Contact's Mobile Phone Number?*
Yes No
Mobile Phone Number*
Area Code Phone Number
Email*

Confirmation Email example@example.com

Section 8: Shipping and Sample Submission
MXNS Shipping Program
As an added value to working with Merieux NutriSciences, our customers have the opportunity to receive significant discounts when shipping their samples to any of our analytical testing laboratories in the United States. You will be provided access to an MXNS shipping web portal which will allow you to generate shipping labels at these discounted rates.
Would you like to participate in the MXNS Shipping Program?
Yes No
Who should have access to the MXNS Shipping Program?
Primary Contact Other (add contact details below)
Shipping Contact
First Name Last Name
Shipping Contact's Phone Number
Area Code Phone Number
Shipping Contact's Email Address
example@example.com
Where will samples be shipped from?
Primary Company Address Other
Address Samples will ship from
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code

Customer Account Setup Form (Rtech Transfer)

Section 1: Company Information