'Excellence in Chemical Distribution'

ICC Customer Information Form

We thank you for doing business with Independent Chemical. Please provide us as much informa?on about your company so that we can provide you with excep?onal service!



Company Information

Type of Business:  

Shipping Information

Delivery/ Receiving Information & Requirements

Delivery/Receiving Days Check all that apply  :
Delivery/Receiving Start Time:   :
Delivery/Receiving End Time:   :
Is an appointment required?  
Preferred delivery of COA:
If COA can be sent by email, enter email address below next to option «Other»
Preferred format for delivery:
If drums are needed, specify type:
Do you have a delivery dock?  
Power liftgate needed?
Note that extra charges may apply

Accounts Payable Information

Accounts Payable Information

Is your company tax-exempt? *

Tax Exempt Information

Tax Exempt Certificate ID#

Please provide us with your tax exempt cer?ficate ID # below. We will also need a copy of your cer?ficate by either 1) Fax to: (718) 894-9224 Aan: Ruby Tsaousis – Accounts Receivable, 2) send Ruthy Villavicencio at Accounts Receivable an e mail to ruthyv@independentchemical.com or 3) upload certificate through link shown on webpage after submiting this form.


TLine of Credit *

Is your company applying for a line of credit from Independent Chemical Corporation If so, please complete the separate credit line application form.


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