Customer Information Form - BIA Analytical

Customer Information Form

Please fill out your business contact information, then hit submit to complete your customer account setup.

Business Name (IN FULL)(Required)

Business Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

VAT Number (Including Country Code)(Required)

Please provide email address or addresses should laboratory results need to be sent(Required)

Please provide email address or addresses to which invoices and e-statements are to be sent(Required)

Contact Details

Please note the main customer account contact

Name(Required)

First Last

Email(Required)

Phone(Required)

Contact Details

Please note the person in the organisation who can be contacted to discuss invoicing/outstanding payment queries

Name(Required)

First Last

Email(Required)

Phone(Required)

Our Biametric™ Services

Please select which service or services you require(Required)

Portable Screening

Laboratory Testing

Authenticator Portal

Bespoke Service

Other

If "other" please describe:

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