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Empire Scientific


Empire Scientific Account Application

Empire Scientific a leading distributor of batteries, adapters and accessories. Access to our website is restricted because we do not sell to the public and the pricing information contained herein is confidential.

 1. Contact information


Name:*
Company:
Address:*
City:*
State:* Zip:*
Country:*
Province:
Phone:*
Fax:
Website:


 2. My account log in

E-mail Address:*
 		Password:
Retype password:


 3. Company information - Optional


Business Type: (choose all that apply)
    Camera/Video Store
    Two-Way Industrial
    Computer Repair Center
    OEM
    Government institution
    Educational institution
    Corporate: IT department
    Corporate: Purchasing department

Number of employees:

Preferred Payment Type:

Are you an existing Empire Scientific customer?
    Yes No

Where did you hear about Empire Scientific ?
    Please Specify:

    Which Search Engine, Magazine, Email, Advertisement
 4. Finish



  



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