New Customer Application Form for Trilogy Flavors

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This field is for validation purposes and should be left unchanged.
Company Name*
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Shipping Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Name*
First Last
Email Address*
Tax ID Number*
Phone*
Fax*
Name of Trilogy Salesperson You Have Worked With*
First Last
Email for Invoices*
FedEx or UPS Account Number*
Preferred Trucker for Collect Shipment*
Are Pallets Required for Truck Shipments?*
- Yes
- No
Special Requirements (Documents, Packing, Etc.)
(If a C of A is required, please provide an email address)
Consent*
I have read and understood the privacy statement*
Consent*
I accept and understand that the ingredients supplied by Trilogy Flavors, Inc. have not been tested, nor have they been determined safe, for inhalation or use in any electronic smoking devices, electronic nicotine delivery systems, electronic cigarettes, or other similar devices (collectively "E-Cigarettes") or in any E-Liquids used with E-Cigarettes. By receiving Trilogy Flavors, Inc. ingredients, the recipient confirms that they will not use these ingredients in connection with the manufacture and distribution of E-Cigarettes, E-Liquids, or any component thereof. WE DISCLAIM, TO THE FULLEST EXTENT PERMITTED BY LAW, ALL WARRANTIES, EXPRESS OR IMPLIED, and disclaim all liability in connection with the use of our ingredients in connection with E-Cigarettes and E-Liquids. All such risks are assumed by you and the user.*
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