U.S. Customer Application Form

Thank you for your interest in Restek. To place an order with us, an account for your company must be established in advance. To set up an account, please complete this electronic application. Payments for new accounts will be established as credit card only, unless you also apply for credit terms. If your company wishes to establish credit, you will have the option to do so after submitting this form.

If you have a question about your application or need assistance with an urgent request, please contact Restek Customer Service by email or call 1-800-356-1688, extension 3.

Fields marked with an asterisk (*) are required.

Company Addresses

Please note that a business address is required; Restek cannot ship to a residential address or P.O. box.

Billing Address

Shipping Address Check box if same as billing address.

Physical Address Check box if same as billing address.

Company Contacts

Bill To

Purchasing Check box if same as "bill to" contact.

Ship To Check box if same as "bill to" contact.

End User Check box if same as "SHIP to" contact.

Default Shipping Information

These selections can be changed for individual orders at the time each order is placed.



Payment for Shipping: *

Tax Status and Required Business Documents

Tax Status *

Acceptable Forms of Documentation

  • Please include a copy of your current business license, state license, DEA registration, or W9.
  • If your business will purchase cannabis standards, submittal of the appropriate business licensing is required.

Please e-mail all documents with your company name in the subject line to Restek’s Customer Service team ( We cannot process your application without this information.

Invoicing Options

Payment Options *

Invoice Delivery Preference *

Reward Rewards Program

Are you interested in participating in our Restek Rewards program? *

Type of Business

Do you plan to resell Restek® products? *

Do you plan to export Restek® products? *

If you export Restek® products you must agree to follow our Export Control Notice.

If we have questions about this application whom should we contact?

There are errors in your application.

Restek Domestic Customer Service



Your Full Name

Your Email

Company Name


Spam Block (Please leave this blank)

all fields required

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