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New Customer Setup Form
Select applicable role below
*
CITGO Marketer Customer
CITGO Marketer
CITGO Sales Account Manager
CITGO Direct Account
Who will be paying for the analysis kits?
End User
Marketer
CITGO
CITGO Marketer Company Name
CITGO Marketer Company Contact
First Name
Last Name
CITGO Marketer Contact Email
example@example.com
CITGO Marketer Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CITGO Sales Account Manager Name
First Name
Last Name
CITGO Sales Account Manager Email
example@example.com
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Let's get the company information for who will be taking the samples
Company Name
*
Primary Contact
*
First Name
Last Name
Primary Contact Email
*
example@example.com
Primary Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Company Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sample Kit Mailing address. If the company address is a PO BOX please select Different below and enter a street address.
*
Same
Different
Do you have a separate billing address?
No
Yes
Shipping Address for Kits
Street Address - No PO Boxes
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing Contact Name
First Name
Last Name
Billing Company Name
Billing Contact Email
example@example.com
Billing Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Billing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Let's figure out who needs to receive reports.
Report recipients
*
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Do you have equipment that you would like uploaded into our database? Upload an Excel or CSV file below.
Upload equipment list here (optional)
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